Tuesday, September 2, 2008

Almost Heaven? A West Virginian Lives through Hell

Tuesday's Tirade
Aiding the Enemy

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” ~Martin Luther King, Jr.

"Denial" stamped by Carelink Health Plans, Inc. of West Virginia on my fourth appeal for medically necessary surgery on July 29, 2005. Yes, it took sending four different appeals before one was stamped as received! A badly, broken system.

Where does one turn? Struggle to locate legal representation. No knowledge of insurance law. Not one person to assist me.

What does the average citizen do? Likely give up at this point. Who would blame them? And the blatant abuse of power continues to the next victim. And the next. And the next. That is until people become angry enough to move on out. Move out in numbers. Move out with loud voices. With determination and passion.

Coventry Health Care, Inc. of Bethesda, “the darling of wall street” and parent company of Carelink Health Plans, Inc. of West Virginia, is unusually good at making profits out of its products. What helps them succeed, it appears, is a state insurance commission who works too hard to insure business remains in West Virginia while the consumer suffers the consequences. Without a real challenge to corporate power and corruption in the West Virginia Insurance Commission, abuses continue.

West Virginia usually finds itself at the bottom of most national rankings: 47th in child poverty, 49th (2006) in the smartest state award, 49th for most obese state, 44th in the USA Health Ratings and 50th in depression. Alarming? A fire is raging in my state. It is out of control.

Considering the dire statistics about West Virginia, it is abhorrent for Coventry to become rich due in part to state government that is working against us.

Government, Senator Barrack Obama exclaimed loudly at the Democratic National Convention should, “help us, not hurt us.” The West Virginia Insurance Commission has not heard that message. They greatly harmed me. No not just once, but again and again.

There is a systemic problem in West Virginia that permeates many offices. What I discovered these past three years is a serious matter.

On January 18, 2008, I filed a claim with the West Virginia Court of Claims against the West Virginia Insurance Commission for obstruction of justice. I cited eleven different serious offenses made against me beginning October of 2005 and continuing to the present. My day in court is will begin on October 10, 2008. I will keep you posted.

Here's a link to the Court of Claims’ response to my legal action: http://www.freewebs.com/courageoffaith/2008%201%2031%20Court%20of%20Claims%20Response.pdf

Complaint One of Eleven Complaints: HIPPA law violated.

Following procedures of state law, on September 29, 2005, I mailed my formal grievance against my HMO to the West Virginia Insurance Commission. With 21 years experience, Dena Wildman is the Examiner in the West Virginia Insurance Commission; it is Wildman's job is to investigate grievances against an HMO.

Wildman and I spoke on the 27th of September, two days before my mailing the complaint to the Commission. Here is my record of our conversation:

Dena is in agreement that insurance companies look at the bottom line as they are a business and as such make a profit. I questioned if a 70% profit (for one quarter) is justified. Wildman replied that many times insurance companies deny and deny and wait for an appeal, hoping “you” will go away. Many people, Wildman believes, do give up.

In 1996 The United States passed a law (HIPPA) which mandates mechanisms be standardized to insure the security of private health information. This information is to be carefully monitored for confidentiality and data integrity for any information that identifies an individual. Keeping your information safe is one of government's most important duties.

On September 28, 2005, I filed a grievance with the West Virginia Insurance Commission against Carelink Health Plans, Inc. Examiner Wildman released all my private documents to Carelink without my authorization.

Without my consent over eighty pages of personal records were sent to Carelink. Records that in the hands of Carelink will compromise my case and any future case. Records of private conversations with others who entrusted me to keep silent about my source.

On June I, 2006, I spoke with Andrew Pauley, Legal Division of the Commission about this travesty of justice. These are my notes of our conversation:

Upon answering the phone, Pauley asked if I was the one who believed the commission erred in handling my case. My answer was ‘yes.’

According to Pauley, there is a place on the complaint form I signed where I can sign that I do not want private information released. Pauley promised to look into this to insure my rights were not violated. Unless this is signed, my information becomes “public” and it’s open to all parties for review.

Pauley never phoned me. I reviewed a copy of the complaint form I completed. It did not request a waiver, as Pauley had believed. It is noteworthy that the complaint form has been edited to today include a waiver of rights. Too late for me. My rights were violated. Yet another case of “Maybe she will go away.”

Link to newly designed West Virginia Insurance Commission Complaint Form:
At the Democratic National Convention threats to the basic rights of US citizens were affirmed. It was Senator Dick Durbin of Illinois who reminded the 40 million people watching "that we should never risk our freedoms and privacy to the overreaching hand of government.”

An overreaching government. It almost sounds like a description from the cold war era. Yet, that is just what I am experiencing in my beloved state. A state in Appalachia, which suffers greatly from a variety of sources already, is compromising private papers.

Health care injustice is shocking. But something is stirring across this country. Once again, it was at the Democratic National Convention when Virginia Governor Tim Kane’s rousing speech called us to “feel the energy of change built upon a faith that “moves mountains.” That change will reach into the very systems that have believed themselves to be beyond the law.

There are many other "faith-filled" people, like myself, who are not keeping silent. They, too, are speaking out in boldness and with passion. Now it is different. There is a new, vital audience that is eager to lead us to victory.

Tuesday’s Tale
Another Coventry Victim Lost the Fight of his Life

As you read today’s tale, remember that this victim and many other victims of our broken health care system, are ordinary people, rich and poor. When serious health problems strike, the system does not rationalize, “This is for a community leader. Let’s provide this benefit.”

You will be evaluated just like the rest of us. A few simple questions will be asked, “Do we want to pay for this expensive procedure?” “Can we escape without harming our image?” “Our business? “How likely is it that this doctor will not go along with us and will test the system?" "How busy is this doctor? "

When you hear those words, “Denied,” and you or someone you love will likely hear them, we will be there to support you. Sooner or later. We will be there. Hopefully, it will not be too late.

It’s too late, however, for Dale Fausset. I am numbed by this story. It could have been me.

WOWT Omaha, April 2008

Dale Fausset dedicated his career to saving lives and now he's fighting for his own.

That survival depends on money and on a decision to authorize the funds but no one at city hall will say who is making the decision.

Transplanted lungs gave Dale new life but they are now trying to kill him.

The donor organs are attacking his bone marrow and he needs a bone marrow transplant from his brother.

But Dale's son and the Omaha Firefighters Union have been notified that the city, which is self-insured, won't pay for the $150,000 procedure.
The family has been told the decision was made by Coventry, the company that administers city benefits.

Coventry won't comment.

Dale's son, Tyler Fausset says, "How it can be considered experimental is unknown to me. It doesn't make any sense, especially when somebody's life is on the line. How experimental can that be? That's what's frustrating."

While Dale battles for his life at a Denver transplant center, doctors’ reports are gathered for an appeal.

Dale spent 27 years as a firefighter and paramedic. He had to make quick decisions to save lives and now he needs one in return.

Zach Ryan, with the firefighters union, says, "The importance of this appeal is paramount to Dale because if it's not overturned Dale will not survive."

For 27 years Dale risked his life for others and his family says the city's insurance company needs to take a risk and pay for his bone marrow transplant.

Tyler says, "For a person who commits his life to helping others, he needs one decision by an insurance company to save his life."

The Omaha Firefighters Union said Thursday night that the appeal had been denied. Neither Coventry nor the city will say who made that decision. An appeal will now go to the City Disputes Board.

An unfortunate update: WT Omaha, May 18, 2008

Omaha firefighter and paramedic Dale Fausset, who fought the city to get coverage for a bone marrow transplant, died Saturday night.

Fausset was forced to wait because the city, which is self-insured, initially wouldn't approve the $150,000 cost. After weeks of fighting, the insurance company settled last month.

Fausset worked for years at Omaha Fire Station 5 (formerly Station 20) as a paramedic shift supervisor, living his life on a watch, always knowing time is everything when saving lives.

But when he needed the bone marrow transplant, his doctors fought with the city's insurance, which called it experimental. He waited nearly three weeks before the city agreed to the procedure.

"During the time that Dale was waiting for approval of the transplant, during that extended period of time, he contracted an infection," says Darren Bates with the Omaha Firefighters Union.

Six On Your Side (Omaha’s television station, WOWT-TV) had previously reported about Fausset’s struggle. When he retired his health deteriorated.

"He really never got an opportunity to enjoy his retirement," says Bates. "He got sick before he left the job."

Fausset had a lung transplant, but it got worse and doctors determined he needed a bone marrow transplant because of complications, but insurance to cover it was denied.

Coventry, the city's health benefits manager, finally agreed to pay for the procedure after an appeal by Fausset, his family, and his union.

"It was a very big extended period of time,” says Bates. “We have been fighting this for a very extended period of time. We were fighting for weeks to get him coverage for the bone marrow transplant."

Others provided chartered flights and fundraisers to offset medical expenses not paid by Coventry.

His brother agreed to donate the bone marrow, but infection took over his body before the bone marrow could take effect.

"He was never able to fight off the infection," says Bates. "The whole idea of the bone marrow transplant was so that his body could begin fighting that kind of infection, producing white cells that would be able to start fighting infections."

Does Coventry really care or it just a public face, a busines decision? Fausset died awaiting authorization for a bone marrow transplant that ought to have been authorized immediately. Authorization did come as was due, but it took so long that Fausset died.

Remember the words of the Examiner of the West Virginia Insurance Commission?

Wildman replied that many times insurance companies deny and deny and wait for an appeal, hoping you will go away. Many people, Wildman believes, do give up.

And some of them die waiting for the benefits they deserved at the very moment the request was made. Shameless. Vile. Evil. Any person who cooperates with this system, no matter to what degree, deserves a prison sentence. That day, I believe, now awaits some.

Before I close today, just ponder how twisted the legal system can be, especially for the poorest of the poor.

On August 10, 2006, I was in the courtroom confronting the evil of Coventry. Only then I did not recognize Coventry’s behavior as such.

Here’s a link to the testimony of Carelink’s Medical Director, Dr. Rod McKinney, D.O. as questioned by Coventry corporate attorney
Jonathan Weinberg Esquire:


Weinberg was questioning Carelink's medical director about the effects on me were I not to have the requested surgery (page 143).

W. In the event that a severe obstructive sleep apnea disorder goes untreated, what are the possible results for the patient?

M. Daytime somnolence and eventually cardiac dysrhythmias, congestive heart failure and things along that line.

W. It is not beyond the realm of possibility that this could be fatal if left untreated?

M. If left untreated for a long period of time, yes.

Skip to Page 166 - a piece of information Weinberg's wants on record:

W. Let me ask you one more question just so we understand it and we're clear....Do you get into-- I mean, would you assume that this is an important procedure to Ms. Stenger?

M. I don't know the clinical (why not? This is the specialist we are led to believe).

W. But no, I'm saying -- I mean, from her perspective___

M. She suffers from severe sleep apnea and to the point it has failed other therapy and intervention, then this would be an important procedure.

W. So you're not saying not important, we're not - you know, get out of here. You, though, have a job to administer a benefit plan which her husband's employer signed up for?

M. Correct.

Don't you want to jump in here and say, "Cut the theatrics, Weinberg. Stop leading the witness. And what's this about a benifit plan that doesn't allow for this surgery? Aren't you getting ahead of yourself here?"

Yes, there were theatrics in that courtroom in 2006.

Saying 'I am sorry' to me was not in the works that year. I was not dead yet.

I believe that one can be sorry only so many times without a public outcry for change. As I search the internet for legal cases against Coventry, I am becoming aware of just how many times a corporate suit said, “We are sorry.”

Coventry no longer has us fooled. Check out this authorization from Carelink for the benefits that Weinberg stated were not mine:


My rightful benefits were granted on April 4, 2007. That's one year, eleven months and four days from the date I requested medically necessary surgery.

I sense that the gig is up. The curtain, praise God, is beginning to fall on this sorry behavior of health plans and the maneuverings and incomplete facts presented by its highly paid legal departments.

Mr. Dale Wolfe, Coventry CEO made $32 million dollars the year before I was denied my request for medically necessary surgery. Certainly an excess that could have gone to pay for my surgery as well as Mr. Fausset’s comparatively cheap procedure of $150,00.00. Mr. Weinberg, Carelink’s representation, appears to represent Coventry interests across this country. I doubt anyone would be surprised by Weinberg’s salary.

More than enough written for this Tuesday, Setember 2, 2008. My goal was to keep it to two pages. There is so much evidence. We'll be here awile.

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