More out of obduracy than out of any sense of hope, I have just now finished writing a second letter of appeal against my son’s medical insurer’s refusal to reimburse the cost of surgery he needed to correct a deformity in his left foot.
I’ve written about my son not having been diagnosed with Spastic diplegia until he was in his mid teens before now (find that previous posting here). What I haven’t written about until now is what his insurers had to say about his diagnosis.
They turned down his claim, of course, not just the once, but twice. In their second letter they wrote, ‘According to the advice of our doctors and research on the literatures of Spastic Diplegia, we gathered that this is essentially a congenital condition which is acquired during pregnancy or during birth process.’
It would not have helped us to pay his bills had our doctor’s first guess as to what might be causing his problem turned out to be correct. My son was presenting all the observable-to-the-naked-eye symptoms of Charcot Marie Tooth disease, a condition that is most-commonly but not always acquired through hereditary.
A Neurologist was able to assure us it wasn’t that, however, nor could it have been any other degenerative condition as there was no evidence of any degeneration in his peripheral nervous system. He arrived at a ‘working diagnosis’ of Spastic diplegia only via a process that involved the exclusion of various other likely culprits then. He would not have been able to achieve this had he not happened to have an instrument called electromyograph in his office.
Further, given that he had appeared completely normal at birth, it was suggested our son must have acquired his Spastic diplegia sometime after birth. Most recently, together with my second appeal, I have enclosed a letter from our Neurologist that states he is now confident, after having checked the records held by my son’s Cardiologist, his Spastic diplegia must have been acquired during a particular cardiac event that took place when my son was still very small.
Unfortunately from the point of view of the validity of my son’s claim, the cardiac event he means to refer to was attributed to Wollf Parkinson White syndrome, a condition I imagine my son’s insurer will be delighted to remind me is quite definitely congenital. It must, therefore, have pre-existed the inception date of my son’s policy. Interestingly though, before the electrocardiogram was invented, the only sure fire way of knowing whether a patient had WPW or not would have been to cut him open and look directly at his heart. Prior to the invention of the electrocardiogram, I’m guessing my son’s claim might have appeared valid then.
What would have happened if our doctors had stopped at ‘suspected Charcot Marie Tooth disease’? Can an insurer justifiably refuse a claim on the basis of what is suspected but not yet proven? What if we had stopped, as the first doctor we consulted suggested we might, at ‘idiopathic Equinus deformity’?
I have my doubts as to whether my argument would stand up in a court of law, and, under the present circumstances, I figure it’s at least worth putting up in the form of an appeal. A lawyer friend told me recently that anyone who can find an excuse to take a medical insurer to court in Singapore
Linked articles: Late Diagnosis of Mild Spastic Diplegia/Cerebral Palsy; Co-insurance and/or Exclusion of Disorders Acquired after the Inception Date of a Private Medical Insurance Policy
Recommended websites: to come
No comments:
Post a Comment