Chemo benefit paid only at Hospital

mags20487

My insurance will only cover chemo and radiation therapy at a hospital.  I have had 6 of 8 chemos and will move on to radiation next.  The last time I went to the hospital for #6 and was turned away.  At first the hospital said that it no longer did chemo for someone who is sent by the doctor.  I explained that it was the only way that my insurance would pay the claim.  They said that they no longer do chemo infusions at their facility.  So the next day I went to the docs office and had the tx at her infusion room.  We had to pay out of pocket for it.  After many phone calls to the insurance co I found out that they were investigating my claims because they thought the cancer may be pre-existing.  I signed up in Feb for the policy so def not a pre exist thing.  That has been taken care of but the hospital will not budge on their policy so I have no options but to finish up chemo at the docs office and pay out of pocket.  So ridiculous. 

I am also having a hard time understanding the radiation part of my policy.  The insurance insists that it must be done at a hospital but no hospitals in town do radiation but the 3 cancer centers do.  I would have to travel an hour each way to get the tx at the nearest hospital with a cancer center attached.  I feel so overwhelmed with all of this.  I told the rep from the insurance that having cancer was enough and i was tired of them playing the word game and it should make no difference WHERE I go for treatment if it is covered.  Spent most of day crying as I just cannot take the extra stress of this right now--plus it has been raining all day and that always changes my mood.

Any suggestions??

Maggie

Sue-61

Maggie, I hear your pain. So many insurance policies are certainly written with too much "fine print." This whole scenario sounds ridiculous to me, but, hey, I used to work for an insurance company so nothing surprises me these days.

My best suggestion is to call your insurance company and see if they have oncology case managers. Case managers are usually highly trained registered nurses who can help their members navigate the health care system. They, unfortunately, do not have magic wands but are supposed to coordinate your care for you in a cost effective manner.

I also think it is unconsionable to try to look for pre existing conditions. Most insurance companies love to take your premiums and then, if you really need to use your benefits, would like to throw you to the wolves.

So take a really big breath and see if there is a casemanager who can help you.

My best to you, Sue

mags20487

I have been in touch with a case manager and she really is not much help....she keeps offering me tips to get thru chemo etc.  I already know that stuff as there are 6 under my belt now.  I have threatened to take my story to the insurance comissioner of FL and that seems to get their attention but still nothing good has come from it.

Maggie

Sue-61

Mags, you have every right to take this to the insurance commissioner. Go for it. And if you get a denial in writing, you also have every right to start the appeals process.

Most insurance companies have a lawyer (mine did) and they are well versed in the "fine print."

Still hoping for a good outcome for you, Sue

ICanDoThis

Oh, you're in Florida.

That explains a lot. 

Wabbit

Have you asked about waivers of those policies ... because hospital treatment is not available to you within a reasonable distance?  The ones I have heard of use 50 miles as the 'reasonable' standard but that could vary.  That is one of those things many insurance company will not tell you ... unless you already know and they have to admit it. 

It all sucks and I am so sorry you are having to go through this.  The truth is that most of us don't find out about all this 'fine print' crap until it bites us.  Contacting the insurance commissioner is a very good idea IMO.

Good luck! 

shells43

The doctor's office/hospital should have gotten everything pre-approved through the insurance before any of this started and let you know if it would not be covered. Something seems very wrong. My radiation was $2000 a day for IMRT so do not start without pre-approval and drive the hour to the hospital if you have to in order to get it covered. You might also check to see if the American Cancer Society has a place to stay near the cancer center that would let you stay there so you don't have to drive daily. I'm in central Fl so IM me if you want to talk.

Shelley

Edited to add I was also dx'd at 43 and my kids are 19 and 22!