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PATIENT STORY

Following Doctor's Advice Leads to Denied Coverage

Dallas George - Davenport, IA
According to personal accounts:

Dallas George was on heart medication when he switched jobs in 1990. When he decided to take the new job, Dallas made sure his new employee health plan would cover future costs related to his previous open heart surgery.

On February 12, 1990, he began experiencing chest pains. Two days later, he was undergoing coronary bypass surgery with prior authorization from his new insurer.

"We got the pre-approval, had the operation, then four months later the bills started coming in. That's when they came up with this argument that they were denying my claims based on a pre-existing condition," George says.

The insurer claimed the second surgery was an extension of treatment initiated with the first operation, as evidenced by the pills George had been taking ever since his first surgery. By following his doctor's advice and taking the pills, George had forged a link of treatment between two operations that were years apart---and had given the insurer a reason to deny coverage.

Because of ERISA, Dallas George and others in his situation can't get damages against insurers who refuse to pay their bills. Future employers aren't likely to offer them insurance, and insurers that do collect premiums can deny coverage with impunity.

"It's a hell of a fix to be in for someone who thinks he has insurance," concluded George.




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