I live in Oregon, and my insurance is Pacific Source. (I hope my flair is correct)
I had extensive and complicated surgery involving a near complete hysterectomy due to a fibroid tumor. It was supposed to be laparoscopic, but the tumor was so large that I had to be opened up right down the middle. The resulting problem is that I now have a huge incisional hernia, with multiple loops of intestine protruding through.
My former hernia specialist said that this is severe, and could very potentially pinch off blood flow to my intestines, killing part of them off. If this happens, I would require emergency surgery to save my organs from dying, and if not done in time, could eventually kill me.
I am in pain 24/7. I sleep for 2 hours on the couch. 2 hours in a La-Z-boy chair, and 2 hours in my bed, before it hurts too much to sleep. I sleep deep enough to dream maybe once every few weeks for a few hours. I am exhausted from the pain and lack of sleep, to the point where driving is dangerous. On a good day I can sit in a chair without moving, concentrate very hard on surfing the internet, and get through the day. On a bad day (or if I do so much much as stand at the sink and hand wash a single load of dishes) I hurt so much I can’t sit still and have to pace in order to distract myself from sobbing from the pain.
My insurance denied me coverage for surgery to repair my hernias twice. The first time, there was a miscommunication by my former hernia specialist and the denial said that they would only cover incisional hernias if my organs were actually protruding through. My doctor amended my medical record to emphasize that organs WERE protruding, and my insurance sent me a second denial, stating that they do not cover hernias AT ALL. (I have sadly lost track of my first denial, so I don’t have documentation that they are telling me two separate stories.)
This is complicated by my former hernia doc, who basically said that if my insurance denied me, there’s nothing else he can do. (Asking him to help me file an appeal has gotten me nowhere, and I was basically hung up on when I asked what else could be done. He will not make any further effort to provide me further care.)
I got so desperate I begged my general practitioner (not the hernia specialist) to prescribe me pain pills so that I can at least sleep/manage my pain. Unfortunately being on pain pills could dull the pain to the point where I wouldn’t know if I was dying from a pinched organ. I got a referral to a new hernia doctor, but am still waiting for that to pan out.
Insurance people are not medical professionals, but somehow they have the power to deny me coverage. Would an advocate even touch my case, seeing as this specific insurance is covering me solely because I don’t have a source of income because I literally cannot work right now? How do I even go about fighting them on this?
[edit]
How did you purchase the insurance?
I applied for it when I first moved to Oregon (4 years ago). I was a new resident of the state, didn’t have a job yet and the insurance itself was fairly new. (I live with my parents, so I have a home to live in.) I was the ‘guinea pig” applicant at the local clinic. Pacific Source accepted me and covers my medication and some preventative care.
Has your surgeon performed a peer to peer review appeal?
My surgeon refused to do anything further the instant he found out I was denied. That’s why he’s my former surgeon. Still waiting for the referral to a Not Shitty Surgeon to bear fruit.
It’s open enrollment, you could switch to a new insurer for 2021.
I’m not sure which insurance to switch to or even how to go about researching.
submitted by /u/Alkuna
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I live in Oregon, and my insurance is Pacific Source. (I hope my flair is correct) I had extensive and complicated surgery involving a near complete hysterectomy due to a fibroid tumor. It was supposed to be laparoscopic, but the tumor was so large that I had to be opened up right down the middle. The resulting problem is that I now have a huge incisional hernia, with multiple loops of intestine protruding through. My former hernia specialist said that this is severe, and could very potentially pinch off blood flow to my intestines, killing part of them off. If this happens, I would require emergency surgery to save my organs from dying, and if not done in time, could eventually kill me. I am in pain 24/7. I sleep for 2 hours on the couch. 2 hours in a La-Z-boy chair, and 2 hours in my bed, before it hurts too much to sleep. I sleep deep enough to dream maybe once every few weeks for a few hours. I am exhausted from the pain and lack of sleep, to the point where driving is dangerous. On a good day I can sit in a chair without moving, concentrate very hard on surfing the internet, and get through the day. On a bad day (or if I do so much much as stand at the sink and hand wash a single load of dishes) I hurt so much I can’t sit still and have to pace in order to distract myself from sobbing from the pain. My insurance denied me coverage for surgery to repair my hernias twice. The first time, there was a miscommunication by my former hernia specialist and the denial said that they would only cover incisional hernias if my organs were actually protruding through. My doctor amended my medical record to emphasize that organs WERE protruding, and my insurance sent me a second denial, stating that they do not cover hernias AT ALL. (I have sadly lost track of my first denial, so I don’t have documentation that they are telling me two separate stories.) This is complicated by my former hernia doc, who basically said that if my insurance denied me, there’s nothing else he can do. (Asking him to help me file an appeal has gotten me nowhere, and I was basically hung up on when I asked what else could be done. He will not make any further effort to provide me further care.) I got so desperate I begged my general practitioner (not the hernia specialist) to prescribe me pain pills so that I can at least sleep/manage my pain. Unfortunately being on pain pills could dull the pain to the point where I wouldn’t know if I was dying from a pinched organ. I got a referral to a new hernia doctor, but am still waiting for that to pan out. Insurance people are not medical professionals, but somehow they have the power to deny me coverage. Would an advocate even touch my case, seeing as this specific insurance is covering me solely because I don’t have a source of income because I literally cannot work right now? How do I even go about fighting them on this? [edit] How did you purchase the insurance? I applied for it when I first moved to Oregon (4 years ago). I was a new resident of the state, didn’t have a job yet and the insurance itself was fairly new. (I live with my parents, so I have a home to live in.) I was the ‘guinea pig” applicant at the local clinic. Pacific Source accepted me and covers my medication and some preventative care. Has your surgeon performed a peer to peer review appeal? My surgeon refused to do anything further the instant he found out I was denied. That’s why he’s my former surgeon. Still waiting for the referral to a Not Shitty Surgeon to bear fruit. It’s open enrollment, you could switch to a new insurer for 2021. I’m not sure which insurance to switch to or even how to go about researching.
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