Edward Mycek – La Quinta, CA
As told by Edward Mycek:
In November of 1997, I found out that I had prostate cancer. After discussing treatment and recovery options, my doctor advocated surgery to remove the prostate. I decided to get another opinion. After consulting with a new doctor at Loma Linda University Medical Center, I decided on a Proton and 3-D Conformal Radiation treatment. The new physician and his staff concluded that I was an excellent candidate for the treatment.
1. The tumor was encapsulated
2. My P.S.A. count was low
3. The results of the bone scan were propitious
4. I am only 54 years old.
The doctors at Loma Linda Medical Center then contacted my insurer, which said that it would pay for the full treatments. In fact, my insurer called back to inform me that the insurance policy covered these treatments and they’d notify the medical center that the procedure had been authorized. The authorization never arrived at the medical center.
Worried about the delay of my care, I called my insurer, who told me that they had reversed the decision. The company claimed that Proton and 3D Conformal Radiation was "experimental and investigational."
Loma Linda then faxed factual information to my insurer which explained that the procedure was not experimental nor investigational. Since June 1996, Medicare, and many other insurance companies, have accepted this procedure. The medical center doctor also wrote a letter that discussed the different recovery rates: for Proton radiation the recovery rate is 98% versus 83% for surgery.
After several stressful weeks, I was still denied help. I asked my insurer what other treatments were covered. They responded by saying "they could not say, it would be practicing medicine." After being passed back and forth, like a ping-pong ball, I couldn’t wait any longer. On February 17, 1998, after paying "up front," I began my first of 44 radiation treatments. This a financial burden on our family. Today, I have completed all 44 radiation treatments, and I am due for a check up next week. I am scheduled with Loma Linda for follow-ups through 2004.
After all is said and done, I still feel that I have been denied needed care by an agent 3000 miles away, seated at a desk and appointed by the company to decide the quality of care I receive.
I have worked for this well known company for almost 32 years and this was the first major claim I made. Because my insurer is protected by "ERISA", I can recover no damages against them. I do not have the resources to pressure my insurer to provide better care. Is this ERISA law a fair and just medical/insurace law to employees?
Not by any means.