Fool me once, shame on you

They do not market blood pressure medication strong enough for days like today.

Mary S., you were right.

To quote from our benefit catalog, p. 47:

Speech Therapy, Speech therapy provided by a speech therapist if all of the following conditions are met:

1. The service of a speech therapist if required to restore a speech disability that the patient lost as direct result of an Illness or Injury.


2. The services of the therapist are prescribed by a Physician who continues to control and direct the overall treatment of the case, as Medically Necessary to improve the specific defect.

When I read that to the case worker (G.O.), she said, "That sounds exactly like Linda." If you don't understand why discovering this little clause made me livid, review kicked out. Notice where I state that "Apparently we don't even have an outpatient speech therapy benefit, and they feel they have been generous in paying for what they have already." This is precisely what G.O. told me on that date.

Most of you have never heard me yell. G.O. has heard me yell. "You told me I didn't have an outpatient speech benefit! That was completely inappropriate!" Her story is that she was just relaying what the insurance company told her.

I told her that she had been negligent in her duties. She is supposed to protect the insurance company from me defrauding them, and she is supposed to protect me from them--and she didn't. You wouldn't believe this possible, but the case worker assigned to me by our own insurance company has no idea of what our benefits are and has no way to look it up.

I told her that they are going to pay for Linda to continue speech therapy as well as her other therapies. She said she would pass my feelings on to the insurance company. I told her, "You can tell them, 'I'm awake now.'"

She said she had not yet received information from yesterday's Rusk visit, so I had Linda's current prescription for 3 months of continued speech therapy faxed to her along with a copy of p. 47 of the benefits booklet. I also re-enrolled Linda for speech at the earliest convenience of the therapist, which is Monday.

G.O. apparently did pass my comments on because the insurance company immediately ordered an independent inquiry into Linda's case by a physician "expert in the field." I learned this later in the day, after G.O. gave me numbers where I could confirm our benefit and get the word directly on why I had been misled about the benefit.

Customer service did in fact verify that the benefit is as stated on p. 47. They asked why I needed to know, and I replied that there had been a discrepancy between what the book says my benefit is and what I was told. I asked the name of the customer service tech and got a first name only. I asked "Is that first name unique?" She asked what I meant by that, and I explained "Usually at a customer service number, the first names given out are unique. No two techs use the same first name." She asked why that mattered, and I told her, "Because if I have to sue you, I want to know that you are the only first name in customer service so I know who I talked to." That got me immediately transferred to a supervisor.

The supervisor also wanted to know why I was requesting the benefit information. I told her, "I need to know whether I should sue you, and I need to know precisely what my benefit is to decide that." She was very diligent and double checked for me. The benefit on p. 47 is in fact our benefit. She also told me that first names are unique.

After my run through customer service, I called the second number I had been given, for G.O's direct contact the insurance company, T.T. According to T.T., Linda was denied for her speech benefit on the sole basis that it was no longer medically necessary. I told her that G.O. had relayed the message that Linda did not qualify for an outpatient speech benefit, that it was not a benefit of our insurance, and I also read p. 47 of the handbook to her.

T.T. seems to have a deficit in the kind of English that most of us speak. She speaks a kind of bully English dialect. Numerous times she asked, "Can Linda speak?" as if this yes/no question is the end-all be-all of "medically necessary." I explained that the question is not pertinent because the benefit is for a "speech disability" and Linda has a speech disability. She did not seem to want the discussion defined in these terms, insisting on her little non sequitur "Can Linda speak?"

That I had the professional opinion of an "expert in the field" and a prescription for continued therapy seems to carry little weight. "You can get a prescription for anything."

In the end, I said I was re-enrolling Linda in speech and they would pay for it because their independent review will correctly find her therapy "medically necessary". I fear this may drag out and involve attorneys before we finish.


So, in the end, the scenario is this: G.O. says she works directly with T.T., and also that she got her false information from the insurance company and simply passed it on. In contrast, T.T. says no one in her office would have said that, because it is false and further their office doesn't actually comment on benefits (that's another office).

So it seems that as the insurance professionals would have it, Linda was the victim of a tragic game of "telephone". What I want to know is, what does one insurance professional say to another insurance professional that starts at one end as the truth and comes out at the other as a bold-faced lie?