Counting My Teeth

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Permalink Reply by Joe Asbury on June 12, 2011 at 10:08pm

Just submitted to both The Fixer and Problem Solver. Gin, I will try to get to the Bike To Work Week event. I generally start work very early so would have to take some time off, but that's an excellent idea.

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Permalink Reply by Bike Bloke on June 12, 2011 at 10:14pm

This whole medical-bureaucratic ordeal is absolutely frightening. In addition to being traumatized by your injuries, you are expected to navigate this morass as if you were an experienced lawyer with at least two legal specialties. I'd be inclined to say, "God help you!", but I don't believe in religion. So it's back to square one.

If I read this correctly, if Humana had the right expertise 'in house', you'd be in good hands and the work could be done without further ado. But the said necessary expertise is not there in the Humana network, and so if they can't do a job they have contracted to do if they received such an insurance claim, they should be obligated to sub-contract the necessary work to dental people who do have the right expertise. No further discussion should be required if Humana is too small or inexperienced to deal with it. Deal with it they have to do, whatever the cost. Maybe that would galvanize them into expanding their network to cover such claim properly.

My other line of thought is this: if a road surface is so defective (as it has proven), the city should be sued for your medical costs - maybe you and Humana could do this jointly? After all, Illinois law does emphasize that cyclists have the same rights and responsibilities as motorists. Let us suppose some kind of bridge defect affected a car driver so that the driver suffered a big loss - you can bet the city would be sued to cover that loss. So why not a cyclist? We are not second class citizens!

Joe, I wish you all the best getting this Kafkaesque nightmare sorted out.

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Permalink Reply by Joe Asbury on June 12, 2011 at 10:38pm

Thanks, BB! This whole thing is so complicated and while I am no scholar on Kafka, it definitely reminds my of Joseph Heller's most famous novel: Catch-22. Humana contracts with Resurrection, who have this tiny network and no one who can do my work. So I look outside their network and actually get permission from them to do so, only to have Humana swoop in and say my choice of providers is out of network. Then when I try to work with someone in the Humana network, they say that they won't cover the work anyway. As for why I can't successfully sue the city, have a look at the links at the end of my blog concerning current legal precedent about cyclists and roadways. Unless you are in a bike lane, you are considered to be a permitted but not intended user, meaning that the roadway does not have to be up to snuff for bike safety.

 

Thanks again for your support!

Joe

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Permalink Reply by Jason W on June 13, 2011 at 9:35am

Ouch man. Good luck to you!

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Permalink Reply by Liz on June 13, 2011 at 11:09am

I don't have any direct good advice, but I'm am very sorry about the situation you have been put in. I wish you the best with your revovery and with your claim.

I would suggest that you reach out out to a lawyer.  

 

I understand how frustrating and painful dealing with managed care can be.  My problems where only addressed when my parents switched healthcare providors.

 

The Illinois department of insurance may also be able to help you with your claim.

http://www.insurance.illinois.gov/healthinsurance/hmos.asp

http://www.ilga.gov/legislation/ilcs/using.asp

 

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Permalink Reply by Liz on June 13, 2011 at 11:20am

"Quinn this afternoon signed a bill that ensures consumers in state-regulated health plans are allowed to have their denied medical claims reviewed by a physician independent of the insurance company and at the plan's expense. About 4 million of Illinois' nearly 13 million people are in private insured plans, which fall under state regulations.

The new rights, which take effect July 1, build on a state law that protects only HMO-covered consumers whose claims are denied. Lawmakers said they wanted to extend the protections to all consumers."

 

"Under the new law, an "external review will be conducted by a qualified, independent doctor, who is selected by a nationally accredited and Illinois Department of Insurance-approved independent review organization," the state said in a statement. The external review must be completed within 20 business days and in urgent cases must be completed within "72 to 120 hours.""

http://www.nationalnursesunited.org/news/entry/new-illinois-law-exp...

 

I'm not sure if you can apply for this after July 1st, since the incident took place before then, but at least its encouraging that some process is being established

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Permalink Reply by Joe Asbury on June 14, 2011 at 9:23am

Thanks, Jason.

Jason W said:

Ouch man. Good luck to you!

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Permalink Reply by Joe Asbury on June 14, 2011 at 9:25am

Liz, thanks so much! A good friend of mine also mentioned that insurance commissioner's office might be a good place to go. I'm not sure if the Illinois Department of Insurance and the insurance commissioner are the same thing but I guess I will find out. Thanks again!

Liz said:

"Quinn this afternoon signed a bill that ensures consumers in state-regulated health plans are allowed to have their denied medical claims reviewed by a physician independent of the insurance company and at the plan's expense. About 4 million of Illinois' nearly 13 million people are in private insured plans, which fall under state regulations.

The new rights, which take effect July 1, build on a state law that protects only HMO-covered consumers whose claims are denied. Lawmakers said they wanted to extend the protections to all consumers."

 

"Under the new law, an "external review will be conducted by a qualified, independent doctor, who is selected by a nationally accredited and Illinois Department of Insurance-approved independent review organization," the state said in a statement. The external review must be completed within 20 business days and in urgent cases must be completed within "72 to 120 hours.""

http://www.nationalnursesunited.org/news/entry/new-illinois-law-exp...

 

I'm not sure if you can apply for this after July 1st, since the incident took place before then, but at least its encouraging that some process is being established

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Permalink Reply by Joe Asbury on June 14, 2011 at 9:50am

After submitting submitting a request to 'The Fixer,' Stephanie Zimmerman, at the Sun Times, I heard back less than a day later. We spoke and it looks like she is on the case! I'm very excited to see what she can accomplish. Thanks to Ricky Rosado and to everyone who has offered support and suggestions. I will continue to update as I learn more.

 

Joe

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Permalink Reply by Julie Aberman (Hochstadter) on June 14, 2011 at 12:21pm

Amazing!

Joe Asbury said:

After submitting submitting a request to 'The Fixer,' Stephanie Zimmerman, at the Sun Times, I heard back less than a day later. We spoke and it looks like she is on the case! I'm very excited to see what she can accomplish. Thanks to Ricky Rosado and to everyone who has offered support and suggestions. I will continue to update as I learn more.

 

Joe

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Permalink Reply by Joe Asbury on June 16, 2011 at 8:02pm

YOU DID IT!!!  I just heard from Humana that they will be covering my dental work! The woman from grievances who called to tell me had definitely read my blog, so good work! All your page hits had an impact. Humana hasn't specified what exactly they will pay for or how much they will reimburse but at least they have agreed to start the process. Thanks so much to everyone! This is a huge deal for me.

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Permalink Reply by Barry Niel Stuart on March 24, 2012 at 3:40pm

Let me suggest that whenever a bridge gets a new deck in Chicago, it gets Slip-Not plates on its outer edges.  These extend in about 8' from the outmost edge on each side.  They can be either solid or perforated.  Milwaukee is installing Slip-Not plates on all new bridges or all bridges getting new decking. Check this out with your Alderman and Mayor Emanual.

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