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High-Dose Chemotherapy: Ensuring Coverage for Your Client, cont'd

How You Get Involved

In most instances your initial involvement will be by way of a telephone call from the patient or, in many instances, her husband, asking you whether or not you can do something to get her coverage for what is perceived, correctly, as potentially life saving treatment. Often, they will tell you that the patient has been scheduled to begin treatment within a few days and that everything that has been tried has been unsuccessful in convincing the health care coverage provider to authorize coverage for the treatment.

The best advice you can give at that instance is to advise that you must review everything you can obtain before giving any further advice.

In order to properly review the situation you will need to receive and read, at least, the following:

1. A complete copy of the health insurance policy or plan involved.
   
   
2. Copies of all correspondence between the health care coverage provider, the medical providers (doctors, hospitals, etc.) and the patient. What the patient doesn't have can, usually, be obtained with just a telephone call, by the patient, to the medical providers. You will find them, in most instances, to be very cooperative.
   
   
3. A general medical history of the patient, which may be contained in the correspondence, so that you can ascertain when she was first diagnosed with cancer. This is critical, for, as is discussed in the Frendreis opinion, if the patient's cancer was known to the carrier at the time the policy was issued, any exclusion of treatment will be looked at most critically by the court with regard to its ambiguity. As pointed out by Judge Marovich, unless the carrier clearly indicates that it does not provide a particular treatment for the cancer, the insured may assume that the policy will cover all of her further required treatment, to whatever extent that may be. Frendreis v. Blue Cross Blue Shield of Michigan, 94 C 1557, ND IL (1995)

It is always best to remind everyone concerned of the urgency for you to receive the requested materials promptly. Suggest that everything be sent to you by FAX or, at least, some type of overnight delivery.

While you are waiting for the materials, it would be a good time to familiarize yourself, as much as possible, with the current decisions on the subject, to assist you in proceeding further. I know of at least one sources of citation lists, maintained as part of a Bone Marrow Transplant network, whom you might want to contact:

Susan Stewart, BMT Newsletter
1985 Spruce Avenue, Highland Park, IL 60035
(847) 831-1913

What to Look For

Now that you have the "package", what are you looking for?

In the correspondence you requested, what you are looking for is pretty straight forward. You need to know:

1. The exact nature of the condition for which the patient is being treated, including, if possible, the date of its onset.
   
2. The exact nature of the contemplated treatment. Are the doctors planning to support the high dose chemotherapy with ABMT or PSCR?
   
3. The exact basis of the denial by the health care coverage provider.

After you have that information, as ammunition, you can now begin to review the health care coverage provider's policy or plan to find out if and how you can shoot it down from its position. Remember, you are going to have to go back to what you learned in Contracts 101 and read the entire policy/plan.