Friday, October 20, 2006

Opinions Are Like...

Girl: Sounds like a subdural hematoma to me.
Dr. Michael Hfuhruhurr: Oh, it does, does it? Well, it's not your job to diagnose.
Girl: But I thought...
Dr. Michael Hfuhruhurr: You thought, you thought. Just go. Three years of nursery school and you think you know it all. Well, you're still wet behind the ears. It's not a subdural hematoma. It's *epidural*. Ha.

This is Chapter Four in the tale of FrankenKristin’s brain. Below is a brief summary of the saga so far. If you would like to read the each installment please visit:

Chapter 1: That's Fronkensteen!!
Chapter 1.5: Point Of Clarification
Chapter 2: You Know I'm A Rather Brilliant Surgeon
Chapter 3: You Have Got To Be Kidding Me!

Let’s recap.

In January 2005, my wife was involved in a car accident leaving her with severe whiplash and a newly diagnosed Arnold Chiari Malformation, which up to this point we did not know it existed. As symptoms worsened she began to focus on the ACM as the primary source of the problem. Since she was unable to find any direction from her chiropractor, nurse practitioner or physical therapist she turned to the internet and found a support group dedicated to assisting people afflicted with this disorder. They directed her to a reputable local neurosurgeon who conducted the most basic of evaluations and determined the ACM asymptomatic.

Finding no one else in Minnesota who specialized in this area, we went The Chiari Institute (TCI) for a definitive second opinion. After determining the ACM to be the cause of her problems and identifying surgery as the only treatment she scheduled an appointment and began to wait the 3 months until her date. During this time we were involved in another car accident which significantly worsened her symptoms and made the need for surgery even more pressing.

With the pain nearly unbearable and the surgery still several weeks off we began the still continuing battle with the insurance companies. At this point the auto insurance company representing the driver in the first accident denied responsibility and his position was supported by a third-party arbitrator.

The driver in the second accident was uninsured so we were unable to go after him for much more than a cost of a doughnut. And since he was not in custody we didn’t know whether we would ever see him again. Furthermore we were quite certain she would exhaust her no-fault benefits through our own carrier and thus began to cut back on acupuncture and massage in order to save up for what we anticipated would be a $100Kplus medical bill. Since TCI was not covered by our health care provider she began the process to request in-network benefits for non-network services.

This is where we pick-up the story.


As I mentioned, the driver in the first accident had denied responsibility and his position was supported by a third party arbitrator. Because of this we had pretty much given up hope getting a settlement. So we had to rely on our own auto insurance company until we were able to come to some sort of arrangement with our health care provider.

Since Minnesota is a no-fault state we were entitled to $20,000 in medical expenses, to be used for whatever we felt was necessary. After the second accident our auto insurance company closed the first claim and opened a new one focusing on the facts of the new case. What we found out later was that although she had not exhausted the original $20,000, all of her treatment from this point on was attributed to the second accident and was deducted from a new pot of money.

This is when the insurance company started to panic.

Because fault in the first accident had been attributed to Kristin and the second was caused by an uninsured driver, there was nowhere for them to go in order to recover their costs. And since it was clear that, due to the pending surgery we would certainly max out our limit, they hoped to avoid the possibility that they might have to continue to pay for her care.

So a few weeks after the second accident, our auto insurance informed us that they had stopped all payment and were demanding that Kristin undergo an Independent Medical Exam. Apparently they were questioning whether the symptoms were really brought on by the car accidents and if so how much should apportioned to each accident.

Don’t let the name fool you, an Independent Medical Exam is anything but independent. In fact, the only choice she had in the matter was what to wear. We were given a date, told when and where to show up and instructed not to contact them for anything other than directions.

The doctor, also a neurosurgeon, began by documenting the facts regarding the accidents and then reviewed her medical history. Later he conducted a neurological exam and while he tried to be accommodating, forced her to do things that caused her significant pain. He asked about our visit to New York and inquired as to whether we were serious about surgery. He of course took a conservative approach and cautioned us against making any hasty decisions.

While he was a nice guy he most certainly did not have our interest in mind. Nor was he truly attempting to form an independent opinion. In fact he made every effort to suggest that Kristin’s Chiari-related symptoms pre-dated the accident and attributed the remainder to the first accident thereby resolving the insurance company of anything other than what was owed us under our no-fault benefits.

But not before he suggested that we get a 3rd opinion. Although he tried to present the suggestion in a diplomatic fashion it was clear that he was simply trying to avoid having to contradict the opinion of Dr. Bolognese, one of the foremost experts in the field of Chiari Malformation. If they could find someone who would say that the situation was not accident related, they might not have to cover anything.

The ironic twist is that the official request for a 3rd opinion was mailed to our house the day after Kristin’s surgery. We were in NY at the time so we didn’t get the letter until I came home a week later. After returning home and speaking with a claims representative, we informed them that we would NOT be seeking a 3rd opinion as Kristin had already undergone surgery. Our claim rep. put Kristin on hold and went to discuss the situation with her supervisor. After asking whether the surgery had been successful, she stated that they would cover up to the limit of no fault benefits, and that then our case would be closed. Although it was only a small protion of total bill it was the first piece of good news we had received so far.

At this point we had gone as far as we could with the car insurance company and now set our sights on obtaining network coverage for The Chiari Institute. This was a whole different battle.

* Dialogue courtesy of The Man With Two Brains.


OneEar said...

Sven, I am interested in and have tried to follow your wife's story.

However, things don't add up. You either are misrepresenting the facts or getting poor legal advice. I'll leave it to you to decide, but, if it is not the former, it is the latter.

Sven said...


I'm not surprised that things don't add up. Imagine being the one with the calculator.

However, I can assure that I am most certainly NOT misrepresenting the facts. As for the legal advice, keep in mind that it has been over a year since the surgery. A lot has changed since then, not the least of which is the progress our attorney has made.

I'll get to that soon enough.

OneEar said...

OK, I look forward to the update.

Attila The Mom said...

I'm am just about fed up to here with insurance companies!

Can't wait to hear more!

kim said...

its amazing what insurance companies get away with on a daily basis ...
sickening actually