This client was getting a treatment for a serious and chronic condition that, if untreated, could diminished his quality of life (energy, stamina, etc.) and severely shorten it. However, the condition was well controlled by a medication infusion that took 3-4 hours every two weeks. The medication was extremely expensive – in the six figures per year. The insurance company could not deny coverage, but did try to save money by decreasing the quality of the delivery of the service.
For the first few years, the infusion was done in a hospital, which ordered the medicine and kept it fresh. It was administered by trained hospital personnel.
To save money, the insurance company decided the infusions should be done in the patient’s home instead. While that may seem convenient, it was the opposite. To this patient, it meant, first, an intrusion into his privacy with family around. Second, there was more opportunities for mistakes, like not keeping the medication fresh, and not obtaining it on a timely basis. Third, there wasn't the security of the backup a hospital could provide in case it was needed. I was asked to help before there was a serious problem.
I first examined the insurance company's promotional and marketing literature, as well as the correspondence and instructions to my client over the years. I noticed that when selling the insurance, nice phrases such as "the best care," "optimal care," "highest standards" were used.
I also realized that the executive who signed some of the correspondence was a medical doctor. She wasn't just a business person in the insurance industry, she was an MD.
Remember, the insurance company had said they covered this treatment, and the hospital infusions had worked well for a number of years. Changing the method of delivery was simply a cost-cutting measure. But it compromised this patient's care. I made the case to the insurance company that it needed to show that the mobile infusion nurse could provide the level of care required under the medical care standards it had promised and under a fair reading of the insurance contract.
They held firm for a while. To ensure continuation of care, I advised my client to try the in-home infusions, even though they were very distressing. However, after the first two home treatments there were problems: The right dosage wasn’t available, it wasn’t fresh medication, etc. As a result, I turned up the heat on the insurance company's lawyers (and the doctors) saying that my client would not wait for a bigger mistake and risk taking ten years off of his life.
Happily, they backed down, and we didn't have to sue them. That was six years ago. He still goes to the hospital twice a month, and has continued a very successful professional and family life.