An Unfair Incident

Delta Winds: A Magazine of Student Essays
A Publication of San Joaquin Delta College
2003

An Unfair Incident

Donna Hagen

It is a very disturbing thing to receive a diagnosis from your doctor that you have cancer. First, there are many questions that need to be answered in regard to the severity of the disease and what the options for treatment are. Then, there is the unhappy task of telling loved ones. Through it all there is the unsettling reality of facing your own mortality. After the initial shock wears off, you will undoubtedly go through a myriad of emotions that may include denial, anger, fear, and grief. None of these things, as unpleasant as they may be, can compare to the worst experience of them all, which is dealing with your insurance company.

A couple of years ago, my husband saw a dermatologist for a skin condition that had plagued him for several years. He had been to our family doctor many times and had tried several different creams and ointments but it only continued to get worse. I'll never forget the day he received the phone call . . . a recent skin biopsy revealed that this stubborn rash was actually a rare form of skin cancer.

As you might imagine, we were devastated. Our doctor reassured us that it had been detected early and was not considered life threatening. We were told about a clinic at Stanford Hospital in Palo Alto, California, which specialized in the treatment and management of this rare disease. The treatment he described consisted of a daily application of a chemotherapy ointment. This ointment, when applied to the skin daily, might halt any further spread of the disease, and in a few cases was even able to completely eradicate it. The doctor insisted that my husband be seen immediately and called to schedule an appointment for him before he even left the office. It was at this first visit to Stanford Hospital that our insurance nightmare began.

I was very relieved when I was told over the phone that Stanford accepted MediCal patients. That first visit included every medical test you could think of and even a few you'd rather not think of, but we drove home thankful that everything possible was being done to keep my husband healthy. When the doctor finally called us with the results, we were happy to hear that in regards to my husband's health everything was going pretty well, but with regard to our insurance we were in big trouble. Apparently, since MediCal was now being underwritten by either Blue Cross or Health Plan of San Joaquin County, my husband could only be seen by a doctor or hospital on their provider list. Neither Stanford Hospital, nor our doctor, was included in that list. He told us there was one other option: to apply for an exemption. This exemption allowed a person with certain diseases such as cancer to be seen by any doctor in the state of California. Unfortunately, this would only apply to future expenses and not the hundreds of dollars we had just unknowingly incurred. I remember thinking that a simple phone call should clear this entire thing up. Nothing could have been further from the truth.

Trying to get through to the Health Plan of San Joaquin County was one of the most irritating and time-consuming things I have had to do. After being put on hold for what seemed like forever, I had to navigate through a phone system with more options than most phones have buttons for and certainly more that I could keep track of. Finally, I was able to speak to a human to explain that I needed an exemption form. We completed the form on the day it arrived and faxed it back to them. Four days later we received a letter in the mail denying our request for exemption because we had not returned the forms on time.

Once again I found myself on the phone navigating the bureaucracy, requesting another form, receiving and faxing it the same day, only to be informed again by mail that we were being denied the exemption because we had not returned the forms in time. By now we realized something was very wrong. We spent the next six weeks calling, faxing, and repeatedly being denied a simple exemption that would allow my husband the treatment he needed to stay healthy. As absurd as this whole thing was, I was sure that a phone call to the right person would fix it. This became one of the biggest nightmares of my life, but the most painful part was yet to come.

During one of my almost daily phone calls to the main office, I asked to speak to a supervisor. The woman who then spoke on the phone had absolutely no compassion for my situation whatsoever. As I once again explained the paperwork cycle I was trapped in, I imagined her to be rolling her eyes, bored to death, perhaps filing her nails as she listened to me plead for her help. In fact I did hear her let out a rather rude yawn. She repeated a list of instructions for me that she had either memorized or was reading from a script. I did my best to keep my composure as I explained to her how many times I had done exactly what she was asking me to do, only to receive a computer-generated letter denying my request. I told her also of the many times that I had called asking for someone to help resolve this situation.

This supervisor was still convinced that I was not in compliance with their procedures and decided to prove this to me by playing me a tape of an earlier conversation we had had. As she played the tape for me, she did not realize that her own comments had been recorded as well. I could clearly hear her joking about what a pest I was. She was mocking me for crying on the phone as I begged her to do something about the situation. She tried to shut the recording off, but it was too late. When she came back on the line, she fumbled over her words. I was so angry I could barely speak. I asked this woman how in the world she could go to work everyday and treat people this way. What she told me caused me great sorrow.

The supervisor on the other end of the line -- who had the power to approve my husband's request for an exemption, which would allow him to receive the needed cancer treatment -- told me that she was very good at her job. I questioned her as to how she defined "good." She proudly told me of her annual bonuses, bonuses given for her "success" at what she did. Her job was to keep people enrolled in the Health Plan of San Joaquin County and apparently she did that using whatever means necessary and at the expense of the health of the patient. Granting my husband an exemption would have threatened her bonus. I was ready to do a little threatening of my own.

I learned that MediCal recipients are allowed to choose between two health plans, Blue Cross and Health Plan of San Joaquin County. This allows for some competition between the two providers and some options for the client. If one entity is not sufficiently meeting the client's needs, then at enrollment time the client could switch to the other. Hopefully, this would encourage each company to do its best so that the enrollees would not switch plans. Exemptions, such as the one we were applying for, are only granted when neither entity is able to provide the specific treatment necessary for serious illnesses like cancer. You would think that, under these circumstances, Health Plan of San Joaquin County would work on behalf of the patient to get the treatment needed, even if it meant losing an enrollee. I am so sad to think that a person in a position of authority would use her power and influence to get bonuses for maintaining accounts rather than for serving the best interests of people whose lives literally depend on the treatment. I'm sorry to say that had I not taken some extreme measures, the employees of Health Plan of San Joaquin County would have been happy to let my husband go on indefinitely without ever getting the treatment he needed as long as he maintained his enrollment status.

Our nightmare finally ended after we wrote letters to elected officials in our area and had our case assigned to an ombudsman. However, this incident really shook our faith in humanity. It is very difficult for me to comprehend how dehumanizing this whole healthcare system has become. We live in a nation that has made some of the most brilliant advances in medicine and yet every day, individuals are denied access to the treatment they need because of health insurance rules and regulations. People suffer in silence while somewhere a clerical worker determines their eligibility to receive benefits. Every day, important decisions, which directly affect the health care an individual receives, are made by individuals whose judgement is being clouded by bonuses dangled before them. In their minds they are "good" at what they do, because they are financially rewarded for it. Perhaps if they had to look into the eyes of the cancer patient desperate for a cure, they would feel a deeper responsibility for what they were really hired to do.