The lifesaver that is the Affordable Care Act

pcip

Health care in our country is a very political animal. Because of the huge amount of money there is to be made, namely by the health insurance industry, there are many special interests trying to claim their piece of the pie, and in doing so they have created the mess that is health and care in this country.

What other democratic and industrialized nation in this world has the process of health care delivery sitting before a court that may well decide that people like my husband don’t deserve to be able to purchase affordable insurance to live? The answer is none.

And why do people who have no idea what it is to have a life-altering or threatening disease, through no fault of their own, feel the need to try and take away health care from those who need it?

I have no answer for that but it is something this family is faced with every single day. From people on Twitter who regularly harangue me for speaking out in favor of the Affordable Care Act to yes, family members who are against it, I have to remind them all that the Affordable Care Act is saving lives. I also remind them that getting sick is part of the human condition and some of us get more sick than others.

And without the Pre-Existing Condition Insurance Plan, my husband and many others would die. It is that simple a truth; that black and white.

We pay a premium every month, just like those who have insurance through their employer. Until 2014 when the law is fully enacted (depending on the Roberts court, of course) and the health insurance exchanges are set up, your employer is the only access point for affordable health care.

The PCIP is a pool of people who the health insurance industry won’t insure. Why? Because the health insurance industry does not like to spread their risk pool out to people with diseases like Multiple Sclerosis or cancer because they know they will have to pay claims for these people. It’s the same with Medicare, the health insurance industry got rid of their most expensive risk pool, those over 65, when Medicare was created.

All insurance is a risk pool, we all pay into that pool to cover each other. I may never have a claim because I am healthy but my money goes to cover those who do and vice versa–that’s how insurance works. Imagine if we just opened up the Medicare risk pool to everyone, cradle to grave, and we all had the chance to pay into it. We’d solve all our problems, both with Medicare solvency and with insuring all our citizens.

The next time you hear someone, anyone, claim the Affordable Care Act is not affordable, ask them if they think it’s all right in this country of ours to allow one industry the right to deny care over and over again while taking in billions in profit.

Ask them if health care is not already “rationed” by the health insurance industry, because it is. Just ask the parents of Kyler Van Nocker or Nataline Sarkisyan.

Ask them if my husband, and other citizens of this country, have the right to be able to see their children grow up by having access to medications.

Ask them if denying access to affordable care isn’t infringing on your personal liberty.

Ask them if they even know that Medicare is a government run program that saves senior citizens from bankruptcy and death.

See what they say and the answer you receive will tell you everything you need to know about their morals and their character. Everything.

Your Money Lost: Group Long Term Disability Insurance Policies

Did you know your tax dollars are used to subsidize private health insurance companies?

If you are unfamiliar with Social Security Disability Insurance, here is an excellent primer put out by AARP. SSDI provides protection specifically to qualified U.S. citizens who become disabled and lose their ability to earn an income. We all pay for this through our Social Security taxes. It’s one of the many benefits of being a United States citizen.

When my husband was employed at Fidelity Investments he had a group disability insurance policy with CIGNA. He even purchased extra coverage–to protect our family with 80% of Paul’s income just in case something happened.

But that money was ill-spent as CIGNA did everything in their power to deny coverage to a man with Progressive-Relapsing Multiple Sclerosis. This is not unusual behavior for any private insurance company. In fact, it’s exactly what they do.

But first, you must apply for Social Security Disability Insurance.

When Paul was mid-way through with short term disability and it appeared he was getting progressively worse and not better, CIGNA telephoned us to inform us that they were getting his file ready for long term disability. Great, we thought, they are helping us! Isn’t that what they collect a premium each month for? The answer to that is, no. They collect a premium each month to make money. Keeping that money and not paying it out in claims helps their bottom line.

From the Group Life Market Survey 2009 outlining the sales in disability insurance, you can see group sales disability totaled $1.3 billion at mid-year, with 27 private insurance companies covering 95% of the total market.

After CIGNA denied Paul’s benefits, they telephoned us again. “You must apply for Social Security benefits and send us proof of your application or your long term application with us will be invalid.”

Why does a private insurance corporation demand that you apply for government benefits?

Money, that’s why. If you qualify and receive Social Security Disability Insurance then your insurance company will off-set the amount of money they contractually owe you by the amount of money you will receive from the government. For example, if Paul’s CIGNA policy was to have paid him $5,000 a month and SSDI would give him $2,000 a month, then CIGNA would subtract that amount and only give Paul $3,000 a month. Your tax dollars are used to subsidize private corporations.

Your money is used to fatten the bottom lines of Aetna, AIG Benefit Solutions (that’s how much now in government money for AIG?) CIGNA, Guardian Life, Hartford Life, Mutual of Omaha, Northwest Mutual, Prudential, Sun Life, UnitedHealthcare, Unum and Wellpoint, to name but a few.

Why pay a premium at all?

An entire industry has been set-up surrounding group disability plans to help private insurers NOT pay the claim.

For example, every year the American Conference Institute (one among many) has a yearly event titled, “Litigating Disability Insurance Claims.” Please click the link and read the brochure–it is so very eye-opening. From the brochure, here is what the insurance companies, their general counsels, federal judges (they are the very same federal judges who will decide your disability case!) and doctors will discuss at the above-mentioned conference, emphasis in blue is mine:

    • Whether the medical record is reliable: Whether the treating physician is biased and favors the patient
    • Providing the credentials of the IME’s (Independent Medical Examiner–hired by insurance company): Identifying what is relevant; Highlighting the appropriate credentials; Ways to appropriately critique the credentials of the IME: what to look for and ways to address the inadequacies; Whether specialized medical knowledge is a necessary component of the IME’s credentials (in the case of Multiple Sclerosis, patients are seen and treated by neurologists, the IME who looked at Paul’s written medical records was not a neurologist and first letter of denial was written by an RN and not a doctor)
    • Rotating vendors to avoid the appearance of bias and to ensure an independent review of the claim
    • The denial factor: How many claims were reviewed and denied?; Whether repetitive denial leads to an appearance of bias; Ways to utilize claim denial information
    • Whether the claimant is constrained by financial pressures and returns to work disabled

The last one is of particular interest to me because that is exactly what happened to this family. This family, faced with zero income as Paul had been the sole bread winner for most of our married lives, had to return to work at Fidelity Investments, disabled. This is something the insurance company counts on to help bolster their claim that you are not disabled.

Medical evidence that you are disabled will not prevail.

This conference, and others like it, focus on how to prevent paying a claim, and it does not matter if the claim is legitimate, what matters is the corporate bottom line. The American Conference Institute also has another conference dedicated to defending ERISA claims attended by more federal judges–the very same ones who will hear your ERISA disability case.

Your premium dollars, the ones you work so very hard to pay each month to your private insurance carrier, are not spent on paying a claim should you wake up one day with cancer, MS or become injured in an accident. No. Those hard earned dollars are spent on figuring out how not to pay you. And then, they use your tax dollars to reduce the amount they owe you.

United States taxpayers, it’s time to say enough. Group long-term disability policies are bogus products. They should either be highly regulated or not allowed to be sold at all, as the poorly written policies and the attendant machines put in place by the insurance companies to deny all claims, make the products fraudulent and worthless.

Links:

CIGNA written brochure for brokers about their long term disability product.

Dell and Schaefer, a law firm, discussing CIGNA including the LINA settlement in California.

The 11 Federal Judges Attending the 2011 Defending and Managing ERISA Litigation Conference.

The American Conference Institute assembles a yearly “defending against ERISA claims” conference usually held in New York City. This year’s conference is at the New York Marriott Downtown.

If you have Multiple Sclerosis or any other disease that forced you to fight for your benefits because companies like CIGNA lied to prevent your claim, then you know all about ERISA or the Employment and Retirement Income Security Act of 1974. Unfortunately, ERISA has had negative consequences. A full explanation, written by an ERISA expert, can be found here.

But you may not know that the very same federal judges who may hear your case attend these conferences where they help coach insurance companies, plan providers and other attorneys on how to defend against ERISA claims. In other words, how to make sure a company like CIGNA doesn’t have to fulfill their contractual obligations and pay your claim. From the conference brochure:

An ERISA Moot Court: Featuring top defense attorneys arguing some of the hottest and most common issues facing ERISA practitioners today, panels of renowned ERISA jurists will critique arguments, question our litigators and help all attendees understand how to successfully convey their positions to the court.

The federal judges, the ones deciding your cases, are going to going to participate in a moot court? That’s rich. And our favorite here at the MS Activism Foundation:

Breaking Up Is Hard to Do: A Focus on Severance Plan Litigation including Triggering Events,COBRA Hang-Ups, and the Other Litigation Issues that Arise in Separation Situations.

CIGNA had a big loss this year in CIGNA v. Amara, even though they are spinning it otherwise, so of course, CIGNA’s senior counsel, Christina McNally will be in attendance at the conference.

Fidelity Investments, my husband’s former employer, is listed on the last page as being in attendance as well. I could not find a name though. Last year it was their very own senior counsel, (and Paul’s fellow Boston College alum) Laura Tholen.

Here are the names and districts of all the federal judges who are attending this year’s conference. And here is a link to the PDF of the 2011 conference. If you are fighting for your claim, and see your judge, send them a letter. Tell them that you know what they’re doing and that it certainly does not appear impartial.

Here are the Codes of Conduct for United States Judges and be sure to ask about CANON 3: A JUDGE SHOULD PERFORM THE DUTIES OF THE OFFICE FAIRLY,IMPARTIALLY AND DILIGENTLY.

 

Hon. Daniel E. Knowles, III U.S. Dist. Ct., E.D. La.

Hon. Morton Denlow U.S. Dist. Ct., N.D. Ill.

Hon. Matthew Kennelly U.S. Dist. Ct., N.D. Ill.

Hon. William S. Duffey, Jr. U.S. Dist. Ct., N.D. Ga.

Hon. Viktor Pohorelsky U.S. Dist. Ct., E.D.N.Y.

Fernando J. Gaitan, Jr. U.S. Dist. Ct., W.D. Mo.

Hon. Timothy C. Batten, Sr.U.S. Dist. Ct., N.D. Ga.

Hon. Robert Jonker U.S. Dist. Ct., W.D. Mo. (I think the American Conference Institute meant MI not MO.)

Hon. Richard G. Stearns U.S. Dist. Ct., D. Mass.

Hon. John Coughenour U.S. Dist. Ct., W.D. Wash.

Hon. Robert B. Collings U.S. Dist. Ct., D. Mass.

Associated Press Reporting Lemtrada (campath) Missing a Goal in Trials.

Associated Press, 07.11.11, 11:29 AM EDT 

NEW YORK — French drugmaker Sanofi said Monday that its multiple sclerosis drug candidate Lemtrada did not achieve one of its goals in a late-stage clinical trial.

Sanofi said Lemtrada worked better than an older drug, Rebif, in preventing relapses, as patients treated with Lemtrada were 55 percent less likely to experience a relapse in symptoms. However, the drug did not prevent their multiple sclerosis from becoming disabling, as it had in previous studies.

Sanofi also listed the side-effects as headache, rash, fever, nausea, flushing, hives, and chills, leaving out the deaths reported in the clinical trials.

I also was very wary when I read the study and they were touting the drug as being able to prevent disability outright. It was even reported that it may reverse brain damage from MS. Nothing short of a miracle, right? Or a selling point worthy of $20.1 billion?

Bits and Pieces; Updates on Campath/Lemtrada, Health Care Reform and the National MS Society.

If you have been following this blog because you or a family member has Multiple Sclerosis you may know about the Sanofi takeover of Genzyme. Alternately, if you are one the many pharmaceuticals or investors or PR and advertising firms that visit us, you already do know that Sanofi completed the $20.1 billion buyout of Genzyme.

Which brings us to Campath (acquired from Bayer by Genzyme) now known, or trying to be known, as Lemtrada. We have written about it here because of the shameful desire to increase the price of a relatively inexpensive cancer treatment to $60,000 per year for Multiple Sclerosis treatment.

It is NOT YET APPROVED for use by the FDA. Campath/Lemtrada is still in clinical trials. Here is a link to the latest in their Clinical Trials.

At one point, Genzyme was giving Campath away for compassionate use in cancer patients. This was done by Genzyme to erase the yearly sales figures so that when the same drug rolls out (when approved) the $60,000 per year price sticker for Multiple Sclerosis won’t have a sales comparison number–of something much, much cheaper. Redefines the whole meaning of compassion, doesn’t it?

______________________________________________________

Health Care Reform:

While the Affordable Care Act is not yet a law–we still have until 2014 for the whole thing to go into effect–the GOP is back to using their favorite catch phrase, “death panels.”

Here is a link to an article in Talking Points Memo about Rep. Phil Gingrey (R-GA) raising the dirty spectre of death panels and rationing yet again. Just an FYI, Rep. Gingrey voted to abolish Medicare. I think the good doctor should know better than to espouse what he does, but here’s the quote:

“[U]nder this IPAB we described that the Democrats put in Obamacare, where a bunch of bureaucrats decide whether you get care, such as continuing on dialysis or cancer chemotherapy, I guarantee you when you withdraw that the patient is going to die,” Gingrey said. “It’s rationing.”

We’re the only democratic and industrialized nation in the world without a universal plan; a plan where anyone can buy into a risk pool and get themselves covered no matter what. We all get sick, it’s part of the human condition. It’s how we treat ourselves that defines our society.

My husband now, having been without insurance for six months, can finally apply to the new high risk pool–thanks to the Affordable Care Act. We ask the representative from Georgia, “What should we do, Dr. Gingrey?” Repeal the health care law like you and every member of the GOP want to do so that my husband (and all other Americans like him) will go without health insurance and health care?

Crying tort reform over and over, as Dr. Gingrey does, isn’t going to fix the system, but considering that the good doctor has himself been sued for malpractice several times, it becomes obvious why he repeats this so often. And why he’s introduced legislation into Congress that would limit damages for pain and suffering from malpractice cases. See H.R. 5 of the 112th Congress.

Dr. Gingrey has this to say about health care reform:

“Just one year has elapsed since the government takeover of our healthcare system and Obamacare has done nothing but create hardships for Americans and place burdens on businesses,” said Congressman Phil Gingrey. “Since its passage, state budgets have been crushed by rising Medicaid costs, businesses have struggled to keep their doors open due to onerous new administrative and tax burdens, and American citizens are being threatened with rising costs and less access to quality care. As we move forward in pursuit of a full repeal of Obamacare, we must stay committed to replacing it with meaningful, cost-cutting reforms that will improve health care, lower costs, and put Americans back to work.”

Government takeover of health care? A proven lie.

If government is so bad, why does Dr. Gingrey want to use government to sharply cut medical malpractice awards? Won’t the free market just sort things out on its own?

But if Dr. Gingrey is speaking about the government creation of a high risk pool to help my husband and all Americans with pre-existing conditions get access to health care by purchasing insurance that will cover them, then I suggest he re-read his Hippocratic Oath.

As for tax burdens and small businesses, small businesses love the Affordable Care Act because they get tax breaks. And read more here, from Fox News.

Are we being threatened by rising costs? Yes. Why? Because Dr. Gingrey and his GOP ilk refuse to expand Medicare to Everyone. A national health plan that would compete for customers may inspire the private health insurers to actually produce a good product. Competition does that. As it is now, the private health insurers have zero competition.

______________________________________________________

Now onto the National Multiple Sclerosis Society:

We got a flyer from the National MS Society the other day about their teleconference series that, “is designed to support individuals with MS through the continuum of their work experiences; from staying employed, to retraining and on to post-employment options. Understanding how to access vital resources will help individuals make the best choices through any stage of their workforce journey.”

With all the money the National MS Society takes in (and spends), this piece of writing just sent me over the edge as it purports to say something without saying anything at all. They paid for that with your donation dollars. And it gets worse:

Applying Through Your Employer’s Long Term Disability Benefits When MS Progresses

Featured speaker Lisa Kantor, LLP from Kantor and Kantor will share her expertise as an advocate who has successfully represented people in Employment Retirement Income Security Act (ERISA) benefit claims for over 18 years. If you have MS and Long Term Disability Insurance through your employer, you will want to know how to apply for and access these vital benefits.

Let me just begin by saying that the whole reason I’m here writing this, the whole reason this Foundation exists is because of the way my husband was treated both by his Long Term Disability insurance carrier, CIGNA.

He was denied his benefits by CIGNA. Twice. We had no where to turn for help, including the MS Society at the time.

This sort of teleconference series makes the National MS Society look good, but doesn’t really help. And with all the money they have, imagine what they could do. They could start by lobbying Congress to fix ERISA–that would go a long way in helping not just those with MS but all who have been denied their benefits or who have been mistreated by their health insurer.

Listening to Ms. Kantor may be helpful, she may even gain a few clients from this teleconference, but she can’t help you “apply for and access these vital benefits.” She simply cannot and that has nothing to do with Ms. Kantor.

See, one cannot actually access their long term disability benefits. I wrote extensively about that over at Illness and Insurance Hell.

Your insurance carrier starts the process while you are still on short-term disability; they will insist you apply for Social Security benefits and prove that you have been through that process or else they’ll deny your claim. They will even offer you help with one of their attorneys to make sure you go through the Social Security process.

To make matters even worse, they will obfuscate the truth (that’s called lying) in the face of medical evidence; they make things up. And when they are threatened with legal action, they send photographers (bad ones I’d like to add) to your house to photograph you and your family. My husband has lesions on his brain and spinal cord, could the guy with the camera, snapping away at us, somehow disprove that?

Then, after all of that, they all attend conferences with federal judges (among others) to figure out how to defend against ERISA claims. Anything not to pay a claim.

Which brings me back to the Affordable Care Act, the Ryan plan to abolish Medicare and the GOP still trying to get rid of health care reform.

I ask this: If the GOP succeeds in repealing health care (doubtful) but say they do, then the provisions in the law that help people, that stop lifetime caps, give seniors free preventative care, that fill the Medicare donut hole, that stops insurers from retroactively cancelling your plan, that gives Medicare drug discounts–if the GOP stops all this then what good is that $8,000 Ryan Voucher?

Eligibility for new health care law’s pre-existing insurance program made more realistic.

We are glad to report some good and sane news today.

The pre-existing insurance plan created as part of The Affordable Care Act has always been a sore point with this Foundation and with many health care activists and with good reason. The eligibility rules surrounding the plan were written with political motivation behind them.

For example, my husband has Multiple Sclerosis and to apply for the high risk pool, he had to go and apply for coverage with a private insurance company and furnish a letter of denial. Not hard to do when one has Progressive-Relapsing Multiple Sclerosis. But think about the ridiculousness of this exercise in futility.

Thankfully, things have changed for the better and certain restrictions are gone.

But there is still one sticking point and that’s the rule stating that a person with a pre-existing condition must be WITHOUT insurance for six months prior to applying to the high risk pool still stands. Progress is slow.

More information can be found from PCIP.gov.

From the LA Times:

The Obama administration, expanding a program created by the new healthcare law, moved Tuesday to make health insurance more affordable and accessible for Americans who have been denied coverage because they are sick.

Across the country, the federal government is reducing premiums on special coverage available to uninsured people with preexisting conditions such as cancer or diabetes.

And the administration is loosening restrictions on who can sign up for so-called preexisting condition insurance plans.

These plans were created by the health overhaul that President Obama signed last year. They are meant to provide temporary aid to sick Americans until 2014, when insurance companies will no longer be allowed deny coverage to people who are sick.

But the number of people signing up for these plans has lagged, in part because of high premiums and stringent eligibility guidelines.

Now, federal officials estimate, premiums in some states could come down as much as 40%, thanks to a more refined analysis of what the plans should charge.

The administration is directly slashing premiums in the District of Columbia and most of the 23 states that have elected to have the federal government run their health plans. The remaining 27 states, which each run their own plans, will be able to reduce premiums, as well.

At the same time, the administration will no longer require applicants for these plans to furnish a letter from an insurance company showing they had been denied coverage. Instead, applicants will need only a letter from a doctor, nurse or physician’s assistant stating they have a medical condition.