Advice needed— Health insurance company

[TC215]

I’ve posted about this a little bit, but my brother was diagnosed with Guillain-Barre Syndrome in March of this year. He woke up one morning unable to feel his legs or walk. While in the hospital, the numbness spread to his hands and face before they were able to stop it. He had a lengthy hospital stay, followed by nearly a month in a rehab facility. He needed to stay longer, but his insurance refused to pay.

He ended up moving in with my parents (he got divorced last year) who have been taking care of him. His recovery has been very slow, but he is making progress. He can stand up unassisted now, but still can’t walk.

My mother has been battling the insurance company this entire time. They are refusing to pay for anything, saying that GBS is a “pre-existing condition,” which is asinine. Apparently that’s normal for them:

https://www.yelp.com/biz/internation...rs-garden-city

It’s nearly impossible for us to get a hold of anyone at the insurance company. If we do get a hold of anyone, they’re not helpful at all. His medical providers have also had trouble getting in touch with them. The insurance company actually hung up on his physical therapist a couple weeks ago.

All of this broke my brother financially early on, and he had to cash out his retirement. He applied for financial assistance through the hospital system, but it was denied because he had $10,000 left from his retirement. We’re in the process of appealing that decision.

He received a bill for over $47,000 today from the hospital. There’s no way anyone in my family can afford this.

I’ve filed complaints with the BBB and the state of New York (where the insurance company is located) so far. I’m trying to file an internal appeal with the insurance company, but can’t get any guidance from them on how to do so.

Does anyone have any advice or recommendations on where to go from here? I’m all ears. This is really taking a toll on my parents, in addition to my brother.

[HeavyDuty]

Did he do a state insurance department complaint?

[HeavyDuty]

This is out of my exact lane, I’m a property and casualty guy and despise life and health. But at some level insurance is insurance.

They aren’t an insurance company, they are a TPA - third party administrator. Was his employer big enough to be self insured?

[TC215]

Did he do a state insurance department complaint?

He can’t do much of anything because his hands still aren’t 100%. I filed a complaint in NY since the company is based there. I can try to do one here, as well.

[HeavyDuty]

He can’t do much of anything because his hands still aren’t 100%. I filed a complaint in NY since the company is based there. I can try to do one here, as well.

Start in his state of residency. And with the state insurance department, not another office. Insurance is highly regulated and the insurance commissioners or equivalent guard their rice bowls.

[TC215]

This is out of my exact lane, I’m a property and casualty guy and despise life and health. But at some level insurance is insurance.

They aren’t an insurance company, they are a TPA - third party administrator. Was his employer big enough to be self insured?

No, unfortunately he had just left law enforcement (with good insurance) and started working as a realtor (I think he was classified as a contractor).

[HeavyDuty]

No, unfortunately he had just left law enforcement (with good insurance) and started working as a realtor (I think he was classified as a contractor).

Ugh. I wonder how he ended up with a TPA?

[TC215]

Ugh. I wonder how he ended up with a TPA?

From what I can tell, it was part of a series of bad decisions.

[TGS]

He received a bill for over $47,000 today from the hospital. There’s no way anyone in my family can afford this.

I know the feeling. I received a $60k+ bill for an emergency surgery that the VA kept trying to not pay. They wouldn't say "no", they just wouldn't actually act on it one way or the other for 9 months.

I can't help on the insurance piece, but in the meantime simple for your guys' mental health, take a look at the hospital and inquire (either directly or indirectly) if they report to the credit bureaus. Most often they do not, and the involved billing parties will simply write off the bill as charity care after X number of months. It was pretty standard at the hospital system I used to work at......only a small portion of patients coming in for emergency care actually paid. The entire system was virtually sustained on outpatient/elective care.

Through some veteran support networks, I learned that the VA was likely failing to act on the bill for this amount of time because instead of negotiating $60k of bills down to $10-$15k, they only ended up having to negotiate $10k down to a couple grand (I don't know how insurance works and whether they might be trying to do the same thing). The rest of the bills* were written off as charity care.

*the hospital is rarely the only biller. Many times, the hospital is simply the facility that hosts other entities to actually perform the work; i.e. my trip to the ER for appendicitis generated a bill from the emergency physician's group that staffed the ER, the surgical physician's group that staffed the surgical unit, the anesthetists' group that put me under for the surgeon to do their thing, the lab, a few other sundry elements, and finally the hospital.

[GJM]

I’ve posted about this a little bit, but my brother was diagnosed with Guillain-Barre Syndrome in March of this year. He woke up one morning unable to feel his legs or walk. While in the hospital, the numbness spread to his hands and face before they were able to stop it. He had a lengthy hospital stay, followed by nearly a month in a rehab facility. He needed to stay longer, but his insurance refused to pay.

He ended up moving in with my parents (he got divorced last year) who have been taking care of him. His recovery has been very slow, but he is making progress. He can stand up unassisted now, but still can’t walk.

My mother has been battling the insurance company this entire time. They are refusing to pay for anything, saying that GBS is a “pre-existing condition,” which is asinine. Apparently that’s normal for them:

https://www.yelp.com/biz/internation...rs-garden-city

It’s nearly impossible for us to get a hold of anyone at the insurance company. If we do get a hold of anyone, they’re not helpful at all. His medical providers have also had trouble getting in touch with them. The insurance company actually hung up on his physical therapist a couple weeks ago.

All of this broke my brother financially early on, and he had to cash out his retirement. He applied for financial assistance through the hospital system, but it was denied because he had $10,000 left from his retirement. We’re in the process of appealing that decision.

He received a bill for over $47,000 today from the hospital. There’s no way anyone in my family can afford this.

I’ve filed complaints with the BBB and the state of New York (where the insurance company is located) so far. I’m trying to file an internal appeal with the insurance company, but can’t get any guidance from them on how to do so.

Does anyone have any advice or recommendations on where to go from here? I’m all ears. This is really taking a toll on my parents, in addition to my brother.

Have you tried contacting the office of the NY insurance commissioner?