How the Health

Editor's note: Malcolm MacDougall, a prominent speechwriter and creative director for advertising firms since the 1960s, responsible for iconic campaigns, such as Diet Coke's 'Just For The Taste Of It,' was diagnosed earlier this year with advanced prostate cancer. This is the story of his struggle with the insurance company over payment for his medical treatment. He paid his premiums, followed his doctors' advice, and yet was still denied coverage for necessary treatments, such as CAT scans and common drugs. Even after the passage of the Affordable Care Act, under which MacDougall found coverage with Health Republic Insurance, thousands of people every day go through what he went through. Sadly, his story is not unique.

How far will a health insurance company go to deny coverage when you are really sick?

How willing are they to risk their customers' health and possibly their lives? Well let me tell you my experience with Health Republic and its affiliate MAGNACARE.

For five months-ever since I was diagnosed with stage four metastasized prostate cancer-they refused to pay my medical bills. On October 20 ^th a nurse with Health Republic overruled my oncologist and my primary care physician and declared that a critical test to determine the progress of my cancer was unnecessary.

It seems she was wrong. As a result, I am writing this from Lenox Hill Hospital where I am undergoing emergency tests and treatments ordered by three prominent New York doctors who didn't agree with that health insurance nurse.

This latest fiasco is not at all surprising. I have been fighting to get Health Republic and MAGNACARE to explain why they suddenly and inexplicably refused to pay for my doctors and my treatments even though I followed their rules for members, went to their online list of providers, and actually received two form letter stating the treatments the doctors had ordered were legitimate.

It's a long story, but if you want to know what it's like dealing with the health insurance bureaucracy when it's a matter of life and death, you might want to stick with me.

My health insurance company have refused to explain why, on every visit, these doctors accepted my Health Republic/MAGNACARE card, and assured me I was 'in network' ... or why the doctors I saw appeared in the insurance company's website of providers ... or why they sent me two letters assuring me that my treatments 'meet criteria and have been certified' ... or why they waited five long, costly months to tell me that my doctors were not 'in network.'

Bottom Line: They won't pay. Period. So don't ask.

But of course, I kept asking. Because cancer treatments are very expensive and I know that I followed the rules every step of the way. I have always tried to be nice when I ask why they won't pay because I know better than to seem angry when dealing with tight-jawed insurance people.

But being nice hasn't helped me make sense of the bizarre, nonsensical reasons my insurance company has used to try to explain why they won't pay. This is a case where delay is denial-with potentially deadly results.

For example, when I asked the broker who sold the policy why my primary care physician, Dr. David McIntosh, appears on the MAGNACARE web site listing in-network providers, he explained that I had used 'the wrong code.' He said I had used the '099 code' instead of he '699 code.' Apparently, it is a very secret code because it had never been given to me. Subject closed.

When I asked the Health Republic customer service phone line representative why all the doctors I saw readily accepted my Health Republic/MAGNACARE insurance card, she said my particular network was 'MAGNACARE Extra' not just MAGNACARE. When I pointed out that my card simply used the name 'MAGNACARE' and that I had never heard of 'MAGNACARE Extra,' she said that was 'too bad.' Subject closed.

When I asked why Health Republic had sent me two letters stating, 'The request for services meets criteria and has been certified,' The representative said firmly, 'we will get back to you on that.' No one has gotten back to me on that.

And when I asked why they had waited five months to inform me that I was not covered for necessary cancer tests and treatments the only answer was, 'We can't possibly inform all of our customers when things like this happen.'

The insurance company, of course, blames the doctors. The broker who sold the policy went so far as to say the doctors had been lying to me. The customer service representative said they had notified the billing service used by my doctors that I was not 'in network.' She could 'not understand' why I was not alerted by them.

The doctors, of course, blame the insurance company. All were genuinely shocked and mystified when they finally learned, on Sept. 4, that I was not covered by MAGNACARE. They all insist that Health Republic/MAGNACARE had not told their billing departments that I was out of network. It seems every step you take leads to yet another maze.

So far, I am out a good deal of money. More importantly, I had to postpone doctor visits and treatments while I tried to untangle the mess. One of those treatments postponed was for injections designed to strengthen bones against further cancer spread. Missing those injections might well have worsened the serious problems I've had to confront.

Shortly thereafter, I found a new oncologist who definitely is 'in network' - Dr. Keith Brunckhorst-a respected New York cancer specialist. His first prescription when I saw him was to have the CAT scan test that I had been forced to postpone for a month and a half.

And so here we go again. Health Republic refuses to pay for the test. A nurse with the insurance company has overruled the opinion of my oncologist-one of their proudly listed 'providers.'

The same test was also recommended by my new primary care doctor, another 'in network' provider. The nurse suggested I have an X-Ray proceeding instead.

On Monday, October 20 ^th, the issue became a very real emergency. My pain hit a barely bearable level. Sleep impossible, I managed to take the train to New York from my home in Connecticut, where Dr. Brunckhorst immediately ordered me to the emergency room at Lenox Hill Hospital. He tried to contact a Health Republic doctor to overrule the nurse and get approval for payment. He was told, by message, that it would take days to get any opinion. But we didn't have days.

'When I asked why they had waited five months to inform me that I was not covered for necessary cancer tests and treatments the only answer was, 'We can't possibly inform all of our customers when things like this happen.'

The doctors and nurses in the emergency room were fast, caring and highly professional. By then, the pain had hit a 9 on my scale-which means it felt like a knife had been thrust into my left side, stabbed the rib bone, then was being pushed again and again into the rib. They tried two strong opiates, found the way to ease the pain, and then sent me to the radiation department to take the CAT scan I should have had much earlier.

Three doctors and a surgeon looked at the results and found that the cancer had spread from rib to spine, and was perilously close to the spinal cord. This is considered a worst-case scenario. They hospitalized me, put me through an MRI, another CAT scan, a biopsy, and commenced the first of five high-voltage radiation therapies.

Obviously, it was an expensive week for somebody. But I was lucky to have instinctively known I had to ignore the health insurer's wishes and make my way to an extraordinary medical team who care deeply about their patients. Five days later and there was still no word from Health Republic.

What are my options now? In early October, Health Republic allowed me to submit a 'grievance claim' which I filed, along with a pile of back-up documents. They still have not acknowledged receipt. And of course, they have never called me to discuss my grievances. I am not holding my breath.

For I know now how this company really feels about their customers. It was perfectly expressed in the letter I received last week when they tried to explain why they were turning down my oncologist's request for that critical cancer test. It was of course a form letter. Very legal. 'The request for outpatient medical services has been reviewed and has not been certified.'

But they gave themselves away with a very strange sentence-their only effort to acknowledge me as a human being. It read: 'Member is over 85 year old and continues to smoke.'

So, that's it. According to my insurers, I have already lived too long. And because, until recently, I enjoyed my two or three cigarettes a day, I am a bad boy who is not worth the cost of keeping alive. No wonder they won't pay.

I think I will frame that letter.

Malcolm MacDougall died five days after writing this. He was 86. Malcolm was forced to fight a Kafkaesque battle with an insurance bureaucracy right to the very closing moments of his life, a struggle that caused him to cancel tests and treatments that could have prolonged his life and would have eased his suffering.

What was the price worth haggling over Mal MacDougall's life? The cost for various treatments and tests vary widely in the New York area, but according to NewChoiceHealth.com -a web site that allows you to compare prices of various health procedures at facilities around the country-an Abdominal MRI at Lenox Hill Hospital has an average list price of $5,400 and a lumbar spine CAT scan of $2,925. The cost to the insurance company is almost certainly lower given their ability to negotiate prices down. Malcolm MacDougall's final days were apparently not worth even that to his insurance company.

Again, his saga is not unique. While difficult to estimate exact numbers, thousands of Americans die every year because of delayed or denied claims. Health Republic responded to The Daily Beast requests for why Malcolm's treatments were delayed or outright rejected with the following: 'Health Republic Insurance of New York reviews coverage requests to determine if service is covered under the member's plan. We ensure that service is delivered within established evidence-based clinical guidelines issued by recognized national authorities. Our reviews are conducted by highly-trained clinicians. In addition, Health Republic has one of the broadest networks of doctors and hospitals in the state, including Memorial Sloan Kettering, one of the leading cancer hospitals in New York and across the country.' The company cited the Health Insurance Portability and Accountability Act (HIPAA), which prevents unauthorized access to all protected health data, for not providing more information, with Health Republic's Director of Media Relations Tara Schuh saying: 'Health Republic is unable to provide any information beyond our internal process for handling claims.' In other words, Malcolm MacDougall is off their books for good.