| 6-1-98 |
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Dear imagenvasca@codeconet.com (Imagen Vasca on line):
I am:
Mr. & Mrs Paul Reali
PO BOX 63
STANDISH
MAINE
04084-0063
USA
(207)642-3614
I am writing to you about CRIES FOR HELP!! NEEDS THE MEDIA'S ATTENTION!.
Mr. and Mrs. Paul Reali
P.O. Box 63, 39 Birch Drive, Pinetree Estates
Standish, ME 04084
Home Phone (207) 642-3614
Email funrus@pivot.net
January 05, 1998
To anyone with compassion for Healthcare victims:
Healthsource has been driving people to their graves and it's high time
people start YELLING! We
have heard horror stories all over the news about the immoral, sinister
treatment Healthsource has given to their patients, but we never thought
it would happen to us. Boy, were we wrong!
My husband was involved in an auto accident in 1994. He sustained injuries
that weren't detectable
by MRI's, cat scans or x-rays. One of which is a brain injury, which
can be worked with; but the injury that has really taken over his mind,
body, soul and entire sense of existence and reality is the neck injury.
He suffers, constantly, from the kind of pain that people commit suicide
to escape from. And what makes it even worse is not seeing any remote chance
of relief. Healthsource is driving my husband to commit suicide by closing
all the doors that could restore his will to live!!!
I apologize for the lengthiness of this letter, but I know of no other
way to stress the magnitude of
the dangerously, vicious abuse that Healthsource has inflict upon my
husband and many other people in his situation! This is a frantically,
desperate, appeal for HELP.
My husband is only 35 years old. We have 3 children who desperately
need their father back! He
has spent 2 years going through every available test known to man (at
least on this side of the U.S.). It wasn't until every other avenue
had been exhausted that his Specialist recommended cervical discography.
Cervical discography is so much more critical and complex than lumbar discography
that there are no known Neurosurgeons on this side of the country that
perform this procedure. My husband’s primary care physician called
in a referral for a Neurosurgeon in New Orleans, Louisiana and on October
17, 1995, Healthsource approved the visit on the basis that “the services
are not currently available through a Healthsource participating provider.”
On March 27, 1996, the surgeon tried a temporary nerve block to
the suspected disks in his neck.
This seemed to take away most of his pain; so he didn’t do the discography.
My husband was sent back to the Pain Center at Brighton Maine Medical,
Portland, to have a permanent nerve block done to the exact area. But,
the same results couldn’t be duplicated so he was no longer a candidate
for a nerve block. Since Healthsource approved this visit to New Orleans
for discography and it wasn’t performed, we assumed they would approve
a visit to a more aggressive Neurosurgeon in Iowa to have this procedure
done.
On November 18, 1996 we received a denial letter from Healthsource for
the discography. Their
reason was that the Specialist didn’t refer the Neurosurgeon. BUT,
it clearly states in the membership agreement that the referral is suppose
to come from the “Primary Care Physician,” which it did! But Healthsource
refused the referral. We figured it was just a minor mix-up somewhere,
but it took 2 months to convince Healthsource that this was the proper
procedure.
Meanwhile, my husbands pain was worsening. So rather than waiting the
60 days for the appeal
decision, we went ahead and made the arrangement to get my husband
to Iowa in confidence that
Healthsource would realize their error and reverse their decision.
My husband’s visit with this
Neurosurgeon showed that he had, at least one, possibly more, ruptured
disks. The source of my
husband’s excruciating pain was finally confirmed. He was told that
fusion would be warranted to repair the ruptured disks and possibly take
away the pain. But, he wanted to perform discography on the disks surrounding
the ruptured disks to be sure there were no others, and he would have to
return to Iowa for that. The cost of this visit come to nearly $9000, and
has been put on our credit report.
In January of 1997, we received the appeal decision...again denied!
WHY? Because they are
now saying that the services are available within the Healthsource
Provider Network. This is the complete opposite of what they stated in
the first request for discography. Not only that, we asked them on numerous
occasions what doctor they had within their Network and were repeated told
that they didn’t have access to that information. That was it!!! Denied!
They furnished no recommendation of any sort...no suggestions as to what
else he could try... they just left my husband hanging and suffering in
agonizing pain!!! Out of pure desperation, we called every doctor possible
to find one who was within the Healthsource Provider Network and were consistently
told that none around here performs cervical discography. We became so
frustrated that, on June 6, 1997, I finally got in touch with the State
of Maine, Bureau of Insurance.
Once they reviewed the sloppy mishandling of this claim, the State of
Maine, Bureau of Insurance
agreed to assist us in a formal appeal to Healthsource. Healthsource
had officially denied the referral
because:
#1. My husband went without approval.
-Which, you will recall,
we didn’t have because of a misinterpretation, on Healthsource’s part,
of the membership agreement.
#2. The service is “not generally accepted” medical practice
and therefore not considered medically necessary.”
-The State of Maine, Bureau
of Insurance argues that “just because a service is not
generally accepted doesn’t make it medically unnecessary or inappropriate.
Furthermore, the letter highlights services that are not considered medically
necessary as (A.) services provided for convenience of member. Which, in
this case, was obviously not convenient! (B.) not appropriate treatment
for diagnosis. Which in this case was the only treatment left for diagnosis.
And (C.) which exceed levels of care needed to provide safe, adequate and
appropriate diagnosis or treatment in the
most cost effective manner. Which, after distinguishing the difference
between lumbar and cervical
discography, you will realize the expertise needed in the cervical
discography field to make this procedure safe and adequate, and it is obviously
appropriate. The State of Maine, Bureau of Insurance agrees on these issues
and has many more issues with violating procedures and regulations.
With the State of Maine and all the doctors backing us, we went through
a formal, in-person, appeal
to the Grievance Committee of Healthsource. Their decision to that
appeal? A second opinion from a doctor of their choice. We agreed and were
confident that this doctor would realize that discography has already diagnosed
part of the problem and that having further discography and possibly fusion
was perfectly logical. This doctor told my husband, during the assessment,
that it made perfect sense to continue with the treatment. That,
once again, boosted my husband’s hopes.
On October 25, 1997, we received the report from the doctor that
said he did not think that further
injections would give him substantial relief, that depression
was the cause of problems and that having discography was unreasonable.
The doctor further stated that my husband hadn’t “participated in any organized
physical therapy program;” which is not true. My husband tried all the
physical therapy recommended right after the accident. Furthermore, the
doctor referred back to the first specialist in New Orleans when he stated
that, “with repeat injections no one has been able to relieve his pain;”
which also is not true. In the next paragraph of the report he states that
he does not have “a formal report of the discography for review.” First
of all, we personally gave him this report during our visit with him; secondly,
we waited a month for this decision because the he wanted to get in touch
with the specialist who performed the discography before rendering his
decision. The Specialist said that the doctor never called him for any
report... and if he had, he would have realized that the injection he gave
my husband, not only did relieve his pain, but confirmed a ruptured disk.
Then, we found out that this doctor doesn’t even handle accident victims.
The State of Maine, Bureau of Insurance agrees that this doctor is not
qualified to render an opinion on an accident victim. This was the straw
that broke the camels back.
This denial drove my husband to having deep-rooted suicidal tendencies.
He has already been
progressively suffering from deep depression, distorted reality and
increasing despondence for nearly a year. He has been talking about suicide
and dreaming of death. He can’t work; he can’t sit and watch t.v.; he can’t
stand still for more than a minute. He can’t play the kids, he can’t hold
his 15-month old son, and he can’t hug me without moaning from the intense
pain. He just can’t live like this anymore! When I informed the psychiatrist
of my husband’s dreams and thoughts of suicide, he recommended a suicide
prevention program at the Jackson Brook Institute in So. Portland.
On December 29. 1997, my husband went to an assessment visit to determine
the appropriate
program for his needs and was referred to the suicide program first
and then the brain injury program after that. My husband’s primary care
physician called in the referral, per policy, and we waited for the approval
before his starting the program, also per policy. He was scheduled to begin
on January 5, 1998, BUT, ONCE AGAIN, Healthsource denied treatment for
a Suicide Prevention Treatment Program!!!! WHY? Because my husband waited
too long between the time of his assessment and the start of the program.
Which was only 5 days, and that was because he didn’t dare start the program
without receiving the approval from Healthsource first!
So Healthsource makes my husband suffer in pain till he just wants to
commit suicide and then they
deny treatment to prevent that too!!!!! Sounds more like attempted
murder to me! This way they can just clean the slate and not have to pay
for anymore treatments. This is pure immoral, vile, torment; not just for
my husband, but for the entire family. It is a violation of everyone’s
right to receive medical treatment! We paid them for it! And now they just
take away my husband’s will to live.
Once again, this is a desperate appeal for help. We do plan to seek
legal action, but that takes
too much time... my husband can’t wait anymore. We need every ounce
of influential support we can get to put the pressure on Healthsource and
force them to approve treatment for my husband. This plea goes out to the
Legislature, District Representatives, advocates for Healthcare, the media,
anyone who can help save yet another victim of the Healthcare system.
Any response, support or guidance in the issue will be so greatly appreciated.
Grateful yours,
Mr. and Mrs. Paul Reali
cc: Senator Susan Collins
Senator Olympia Snowe
Senator William O’Gara
John Baldacci, House of
Representative
Thomas Allen, House of Representative
Adam Mack, House of Representative
News Center 6
ABC News
Public Eye (CBS)
CNN News
Dateline
Nightly News
Portland Press Herald
Consumers for Conservative
Healthcare
Alice Knapp, State of Maine,
Bureau of Insurance
Law Office of Larry Smith
BTW: This message was sent through the INFOSEARCH "Mr. Smith E-Mails
The Media(sm)" site at: http://www.mrsmith.com.
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