So far, so bad...the continuing insurance saga...

[Katie]

Remember when I came back from Dr. Bitan's office, with the diagnosis of the need for emergency surgery especially in the cervical levels? That I was at risk of quadriplegia if I didn't have surgery right away?

I came back and submittted an excellent letter from Dr. Bitan that met every letter of the law needed to have this approved by our provincial insurance. It had to state that I was at risk of permanent tissue damage or death, that the surgery was available in Ontario but unable to be gotten in a 'timely manner', and an Ontario doctor signed the application. Done. So you think it should have been expidited, correct?

NO! Of course not!! I called late last week, after they had had it for a week, asking about the status, and was told that it sat on an agent's desk for just over four days until they realized the person was on vacation, then shuffled onto another desk.

That person is now LOOKING FOR AN ONTARIO DOCTOR TO DO THE SURGERY! And they have contacted my PM doctor who filled out the application, wanting her to refer me to their hand picked surgeons.

Only trouble is, she is away at a convention and won't be back for a week. So we will be into week three for an urgent application. The kicker is that for a year and a half, this insurance office has been refusing to give me that exact information...the names of the doctors that can do the very serious surgery...five levels now...because none of the doctors I've been working with, nor myself working on it almost full time, could come up with any who were qualified to do ADR at both cervical AND lumbar levels. Now I need to have someone do hybrids, as per Dr. Bitan's diagnosis.

Magically, after refusing for all that time by telling me it is not their job to do that, they have jumped in when I produced a letter that they legally have to fulfill. And they are telling me that they have 'some doctors' available now, on short notice.

There are several problems with this...none of these doctors have much experience with ADR. Over the past seven years, the fifteen qualified doctors here have only collectively put in 131 artificial discs. None of them have done more than sixty in total. I am being forced to accept less than acceptable surgeons, in my opinion. And what will be their idea of a reasonable time frame? I've already waited three years to find a doctor to treat me, to no avail. Dr. Bitan wanted me to stay there, or return within the month of April for surgery, and now we will be looking at least to July or August, once the system trickles through, the doctor gets back from the conference, she sends out my records, I get an appointment for a consult, etc, etc. and then maybe book surgery. I am beyond furious.

I have contacted a very high end law firm who specializes in out of country application battles with this province and should be starting on the case later today. Whether or not they get me in any sooner is still questionable, but at least they may be able to get me to Dr. Bitan at least, instead of one of these *#@* 'experts' up here. Five levels...five. I'd be amazed if any have done this very often, if ever.

And I'm betting that they will disagree with Dr. Bitan's diagnosis and try to get away with a lesser surgery...fewer levels or something of that nature.

This is going to be an interesting ride...hang on for the adventure! Sorry to have to vent here...I did most of it yesterday with the lawyer via email, as the one I wanted is out of town and I am being sent to an equally good but different one who is not as familiar with my case. I had originally spoken to them a year ago and got some helpful information about putting my original appeal together back then.

I am also tempted to start that appeal back up again, and try for Germany at the same time. One of the reasons I postponed that one was because it was going to take up to six months for an answer, and also at the time of the appeal, I was very ill from pneumonia and just did not feel that I could present a good case in that state. Plus Dr. Bitan's consult had just come up and it looked like a no-brainer that I would be approved for that, since the application filled all the necessary requirements by law. Guess they are above that now.

[Justin]

Remember when I came back from Dr. Bitan's office, with the diagnosis of the need for emergency surgery especially in the cervical levels? That I was at risk of quadriplegia if I didn't have surgery right away?

I came back and submittted an excellent letter from Dr. Bitan that met every letter of the law needed to have this approved by our provincial insurance. It had to state that I was at risk of permanent tissue damage or death, that the surgery was available in Ontario but unable to be gotten in a 'timely manner', and an Ontario doctor signed the application. Done. So you think it should have been expidited, correct?

NO! Of course not!! I called late last week, after they had had it for a week, asking about the status, and was told that it sat on an agent's desk for just over four days until they realized the person was on vacation, then shuffled onto another desk.

That person is now LOOKING FOR AN ONTARIO DOCTOR TO DO THE SURGERY! And they have contacted my PM doctor who filled out the application, wanting her to refer me to their hand picked surgeons.

Only trouble is, she is away at a convention and won't be back for a week. So we will be into week three for an urgent application. The kicker is that for a year and a half, this insurance office has been refusing to give me that exact information...the names of the doctors that can do the very serious surgery...five levels now...because none of the doctors I've been working with, nor myself working on it almost full time, could come up with any who were qualified to do ADR at both cervical AND lumbar levels. Now I need to have someone do hybrids, as per Dr. Bitan's diagnosis.

Magically, after refusing for all that time by telling me it is not their job to do that, they have jumped in when I produced a letter that they legally have to fulfill. And they are telling me that they have 'some doctors' available now, on short notice.

This is absolutely ridiculous. They actually think that they can ignore your situation for years and then set you up with a surgeon that you don't even know or are comfortable with? Ya know, I've gotten the 'ole "It was on so and so's desk and they've been out of town" so many times regarding insurance matters. It's a cover for laziness, pure and simple. My blood is boiling hearing this news Katie.

There are several problems with this...none of these doctors have much experience with ADR. Over the past seven years, the fifteen qualified doctors here have only collectively put in 131 artificial discs. None of them have done more than sixty in total. I am being forced to accept less than acceptable surgeons, in my opinion. And what will be their idea of a reasonable time frame? I've already waited three years to find a doctor to treat me, to no avail. Dr. Bitan wanted me to stay there, or return within the month of April for surgery, and now we will be looking at least to July or August, once the system trickles through, the doctor gets back from the conference, she sends out my records, I get an appointment for a consult, etc, etc. and then maybe book surgery. I am beyond furious.

I have contacted a very high end law firm who specializes in out of country application battles with this province and should be starting on the case later today. Whether or not they get me in any sooner is still questionable, but at least they may be able to get me to Dr. Bitan at least, instead of one of these *#@* 'experts' up here. Five levels...five. I'd be amazed if any have done this very often, if ever.

And I'm betting that they will disagree with Dr. Bitan's diagnosis and try to get away with a lesser surgery...fewer levels or something of that nature.

I'm glad you contacted a lawyer--they've opened a can of worms. I truly hope they get hit hard for this kind of negligence. Of course, they are going to disagree with Dr. Bitan's diagnosis--and you know who ends up having to wait and suffer--it's you! This is down right criminal. All of sudden they pay attention when someone else spells out quadriplegia or death. I am so sorry you are having to endure this absolute nonsense when you truly need to be treated ASAP. Unbelievable.

This is going to be an interesting ride...hang on for the adventure! Sorry to have to vent here...I did most of it yesterday with the lawyer via email, as the one I wanted is out of town and I am being sent to an equally good but different one who is not as familiar with my case. I had originally spoken to them a year ago and got some helpful information about putting my original appeal together back then.

No apologies for venting--this is the EXACT place you should be venting and reaching out for support. Vent all you want honestly...type everything out if need be.

I am also tempted to start that appeal back up again, and try for Germany at the same time. One of the reasons I postponed that one was because it was going to take up to six months for an answer, and also at the time of the appeal, I was very ill from pneumonia and just did not feel that I could present a good case in that state. Plus Dr. Bitan's consult had just come up and it looked like a no-brainer that I would be approved for that, since the application filled all the necessary requirements by law. Guess they are above that now.

Uggh. I would say if you can do both, with all the pain you are in, then it's worth your time. If you need any help, please don't hesitate to PM or email me. I am more than willing to help in any way I can.

Thanks for sharing this news with the community, and do know that we are here for you.

[Katie]

Thanks Justin, Now it's just time for a good ol' fashioned stress reliever...bawling my eyes out.

I'll compose my self and be back later.

Oh, and they sent me a new retainer agreement...four times the old one, I guess since we are starting with a 'new' subject....I'm going to try and ask that we stay at the same rate as last year.

[Justin]

Good luck! Please let me know if you need anything.

[SemperFi]

In your locale do the doctors practice more or less in adherence to *standards of practice in the community*? Because if this is such as specialized case that it would take outside expertise to perform the surgery hopefully the attorney can shake a stick at that and say these surgeons are not qualified to perform a surgery of this magnitude and could potentially even put the patient at greater risk if not addressing all necessary levels adequately.

Katie, I hope you get somewhere fast with this and can move on surgically as necessary. It's your neck and you've got to do what's best for you~ if at all possible/feasible financially.

[Terry Newton]

Katie:

I have been wondering what has been happening for you lately. I asked on another one of your posts and, didn't hear back so, I have been very curious on how this was coming along.

Keep strong and I hope that this lawyer can get things expedited for you. Hang in there.

[Katie]

Semper, I'm not quite sure I understand what you're asking....I'm a bit fuzzy...sorry.

However, this below is exactly what I'm hoping for.

"Because if this is such as specialized case that it would take outside expertise to perform the surgery hopefully the attorney can shake a stick at that and say these surgeons are not qualified to perform a surgery of this magnitude and could potentially even put the patient at greater risk if not addressing all necessary levels adequately."


I have looked for over a year and a half for someone here who can do both levels of ADR, and have come up dry. My PM doctor, who they are now going after to refer me to one of 'theirs', checked with several of the local Orthopedic Surgeons in our city with the same question, and was told that they knew of no one in Ontario who did the surgery. So she didn't pursue it any further. I did, and found no one.

Sure, some may do fusion, and a few may do either cervical or lumbar ADR, but I sure couldn't find anyone advertising the whole meal deal. I am very afraid of having any one of them work on me, as apparently they are now saying it is something that is done in this province.

Terry, I am so sorry that I didn't answer your previous post...I guess I missed it.

I did call the Appeal Board on Friday to ask for direction. I had postponed my appeal to go to Germany a couple of months ago, as I described above. I asked her if I could get a new date, to go ahead with that now...pushing all the buttons I can, basically.

She said that with it being summer, a normal appeal board would be difficult to put together, as people are starting to go on vacation. The earliest I could go before the board would be late July, early August, if I'm lucky. And then the kicker...they can take up to six months to give a decision.

But, if I just wait to see what happens with this new application, to see if they are going to come up with a doctor for me within a couple of months, I am free to refuse to go to him if I have good cause, and they would call an emergency Appeal meeting. And, the answer would be given within a week or two, as compared to six months or so with a 'regular' Appeal. I just don't understand this system!

So, worse comes to worse, I wait for their referred doctor, say I won't go to them for surgery, and have the appeal board set a date and have an answer within a month. This is assuming that the insurance won't drag their heels about agreeing to the date of the Appeal. They could say they are not prepared to go to trial/hearing and delay me for a very long time. I think they have 60 days to respond...something like that....two months! On top of the six weeks to date I have already been waiting...plus the referral in between. Let's see...first of April to September/October maybe...that's really expedited

They will make me travel to see these doctors, I'm assuming, as one of their arguments against allowing me to go to Germany was that the German doctors had not diagnosed me in person, just by my MRIs etc. So they can't do the same here now, can they? I will not have surgery with a doctor I've never seen here. Germany is somewhat different...I've investigated them for almost two years now...feel like they are family, with all the past patients I've talked to.

I just can't afford either the time or money to travel all over the province to see these guys either, and how many will they want me to see? The closest ones will be at least five to six hours drive away, up to seven. Plus the cost of travel and accommodations...eek!

Sorry for the second vent! The only good thing is that the lawyer agreed to lower the price to almost the same as last year....about a third of normal billing...so I can start to breath again. I sure hope they can come up with more than I can with this. Maybe just their name will stir the pot...fingers crossed.

Thanks for the support with this nightmare...if you are still reading, you have a lot of patience!

[KBear]

Katie, The squeaky wheel gets the grease and it sounds like you are squeaking, rattling and falling off! Hopefully they will just say yes to get you off their butts! Will say a prayer for you.

[SemperFi]

Katie,
Here in the US the doctors are supposed to practice w/in certain "standards in the community" which basically means don't do anything that you can get sued for~

I was just thinking that if your case is so risky for quadraplegia and these locals aren't able to perform what is necessary to keep you from going there that the attorney can argue for the necessity to go outside the community and get expertise in treatment that can handle the magnitude of your surgery(vs. the type of surgery offered in your locale). It's really just a point of arguement really.

I hope that's a bit clearer.. then again maybe it's different there than in the US because we are a "suit (lawsuit) happy society."

[Katie]

Thanks, that's a lot clearer.

The issue here is that almost all the doctors here are under government funding, and laws. I haven't found out yet how 'sue-able' they are...whether I go after the individual doctors who screw up, or the government itself.

The law firm I have hired has successfully taken the government body to court regarding other out-of-country rulings; in effect changing the way the system works. Unfortunately it doesn't have anything to do with my case. But I digress. Just to say that this firm is one of the best for this job.

The other thing is that I'm sure many doctors think they are good enough, till after the fact...ooops is not a word I want to hear. Especially if I can't sue them as an individual...what is stopping them from being over-zealous?

I don't know how risky this surgery actually is...it is a hybrid, an ADR plus a fusion at both cervical and lumbar levels. Dr. Bitan made it sound simple...it is the condition I am in at the moment that is critical...a small fall or fender bender can make me a quadraplegic.

But since so few doctors here have done ADR in itself, let alone a hybrid, that's what scares me, and that's when what you are talking about comes into play. It is probably simple for Dr. B, just not for the regular spine surgeon here...it is their egos that worry me.

I'm sorry, I feel like I'm rambling here...does this make sense?

Cathy, I've been told that I am very well known in the insurance office, that this is a very active case. You'd think they would have wanted to get rid of me a very long time ago...they just haven't figured out that I am way more stubborn than they are. I doubt that many other patients have hung on this long. And that's what they are hoping for...that I will just die or go away out of frustration. They obviously don't know me well enough