Articles Posted in Health Insurance

Breast cancer is the most common cancer diagnosed among women in the United States and is the second leading cause of death among women after lung cancer. On average, every 2 minutes a woman is diagnosed with breast cancer in the United States.

In 2017, 47,000 Americans died by suicide and 17.3 million adults suffered at least one major depressive episode. When I see statistics like those, my mind floods with a flurry of thoughts all at once:

  • “Why?”
  • “How many more have died by suicide since 2017?”

I highly recommend the NPR series, “Bill of the Month,” which offers an expert analysis of medical bill surprises. This month’s bill concerns jaw surgery and a hospital bill of more than $27,000. The patient, Ely Bair, had a condition requiring two jaw surgeries. The first jaw surgery went very well and Bair paid his out of pocket maximum of $3,000 and his employer’s health plan with Premera Blue Cross covered the rest.

Bair’s second jaw surgery was with the same hospital and the health insurer was also Premera. But this time, Bair received a bill of $27,119 from the hospital.

The reason is in the fine print. Although Bair was covered under Premera policies for both surgeries, he changed employers between the two surgeries. Although both employers used Premera, the insurance coverage provided by Premera was different with each employer. The second Premera plan had a lifetime maximum of $5,000 for this jaw surgery. That left Bair responsible for the rest of the hospital bill. When he appealed, Premera pointed him to the specific language in the 80-page policy that addresses the lifetime maximum for this specific surgery.

On August 23, 2021 Kantor & Kantor, LLP filed a complaint against Blue Shield of California in the Superior Court for the State of California, County of Los Angeles alleging Breach of Contract, Breach of the Implied Covenant of Good Faith and Fair Dealing, and violation of California Civil Code Section 3428.

After a routine mammogram in 2013, and a subsequent biopsy, Kantor & Kantor’s client, a 59-year old woman, was advised her risk of developing breast cancer was higher than the general population based on the presence of the papillomatous tissue. Upon being advised that she would be a good candidate for one stage breast reconstruction, plaintiff underwent a bilateral mastectomy with bilateral breast reconstruction in February of 2014.

In 2019 the plaintiff contacted her surgeon reporting chronic pain over the chest wall and into her back, despite physical therapy. Plaintiff reported that the pain had gotten consistently worse over a few years and was limiting her activity and causing daily pain.

Lipedema is a condition that causes excess fat to accumulate in the lower part of the body. Lipedema most often involves the buttocks, thighs, and calves. The upper arms can also be affected. The condition does not affect the hands or feet. It can also lead to debilitating symptoms if left untreated, including chronic pain and the inability to walk or move around easily.

What Causes Lipedema?

The exact cause of lipedema is unknown. But the condition runs in families and may be inherited. The condition occurs almost exclusively in women, and usually starts or gets worse at the time of puberty, pregnancy, or menopause. Because of this, there is likely a connection to hormones. Lipedema is not caused by obesity but more than half of patients with this condition are overweight or obese.

The internet provides patients with the resources to locate healthcare providers anywhere in the world. But whether your health insurance pay benefits for treatment with a health care provider anywhere in the world is another issue. Patients are often unhappily surprised when they discover that their health insurance policy limits them to healthcare only within their state or within the health insurance company’s network of providers.

The first step to understanding your health insurance coverage is requesting a copy of the policy. The policy dictates your healthcare coverage. Review your policy to learn whether your policy provides benefits if you go out of state, or out of the country, or see an out-of-network provider for treatment.

If the policy limits you to in-network or in-state benefits and you find a healthcare provider that is perfect for your needs, don’t lose hope. If you can show that there is no in-network or in-state health provider appropriate to treat you, you have a good argument for asking for out-of-network or out-of-state coverage even if the policy only approves in-network or in-state providers. The best argument will demonstrate that there are no in-network providers willing to take new patients or it is outside of their area of expertise. This argument will require through research through many telephone calls to in-network providers to determine whether they will accept the patient. Similarly with out-of-state providers, the argument requires research to demonstrate that there are no in-state providers available.

Glioblastoma, also known as glioblastoma multiforme, is an aggressive type of cancer that can occur in the brain or spinal cord. Glioblastoma can occur at any age but tends to occur more often in older adults. Many glioblastoma symptoms develop slowly and get worse over time. Common symptoms may include:

  • Headaches
  • Loss of appetite

This Kaiser Health News article highlights the challenges of women attempting to obtain coverage for appropriate birth control options recommended by their physicians.

The article shows how insurance coverage is driven by a chart developed by the FDA for consumer education, not intended to exclude insurance coverage for other types of birth control.

Insurance companies further restrict coverage by limiting options to a list of approved products and requiring patients to given reasons why they cannot use other forms of contraceptive methods before other products will be approved.

Aaron Monheim, age 34, lives in Spokane, Washington with his wife and three year old daughter. In 2019, Aaron was diagnosed with aggressive relapsing remitting multiple sclerosis which has been unresponsive to medications and leaves Aaron partially disabled due to frequent flares and relapses.

Aaron’s physicians recommended him to receive a treatment called hematopoietic stem cell transplantation, found to be particularly suited for his form of relapsing remitting multiple sclerosis. The treatment will effectively reset his immune system so it will no longer attack his central nervous system. The treatment is also less costly than the traditional medications for multiple sclerosis which have been unsuccessful for Aaron.

Despite having been referred to the treatment by his own Kaiser doctor, Aaron’s health plan, Kaiser Permanente, has denied benefits for the treatment claiming the treatment is not necessary or suited for Aaron’s condition.

Multiple sclerosis (MS) is a potentially disabling disease of the brain and spinal cord (central nervous system). In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems between your brain and the rest of your body. Eventually, the disease can cause permanent damage or deterioration of the nerves.

Signs and symptoms of MS vary widely and depend on the amount of nerve damage and which nerves are affected. Some people with severe MS may lose the ability to walk independently or at all, while others may experience long periods of remission without any new symptoms. While there is no cure for MS, treatments can help speed recovery from attacks, modify the course of the disease, and manage symptoms.

The National MS Society estimates that more than 2.3 million people have a diagnosis of MS worldwide and approximately 1 million people over the age of 18 in the United States have a diagnosis of MS.

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