Next week I’m going back to South Africa for an operation. The procedure I require is an “Uvulopalatopharyngoplasty” to fix a deviated septum and sort my throat and pallet out to cure the Sleep Apnoea from which I suffer from that keeps me from a good night’s rest because I choke in my sleep. It will also stop me snoring. I have KT’s blessing (instruction) for this operation! Just kidding. To be honest, it is quite serious.
I wrote about this little while ago about medical insurances and how pissed I was that they never work out for you when you need them the most because they declined this as an uncovered item.
I would like to correct that statement, if you will allow me, to read like this: “Medical insurance never works out for you when you need them the most, unless you kick up a huge stinking fight with them”. Never give up… APPEAL!
That little introduction was my way of saying, “I WON THE FIGHT”. I said I was going to appeal and by golly I did. I wrote an appeal letter from hell. If nothing else I bored them into submission. I can imagine them all sitting there in their little white coats scratching their heads going, “Damn just pay this guy out. Our hourly rate reading all this is going to cost us more than the operation”.
I will drop a couple of the things I used: (Feel free to use this as a cure for insomnia)
- This appeal follows the denial of cover on a pre-authorisation request. Please review all documents as attached and enclosed with this letter.
- Among the documentation is research material from your own Mayo Clinic, considered the renowned research establishment in the USA stating how serious a condition this can be with it being the cause of up to 60% of deaths in slumber.
- I have also included a small bio on Dr ******* describing who he is in his field and I would also like to add that he is the equivalent of an assistant professor at the world famous Groote Schuur hospital in Cape Town which happens to be the leading ENT research facility in South Africa and also the location of the worlds first heart transplant.
- The review board is either stating that they dispute a leading ENT specialist’s diagnosis without further consultation or that heart failure isn’t serious enough to be covered by any medical at the present time.
- The costs, inclusive of airfare to Cape Town, without unforeseen complications, should not exceed $7000. The later alternative heart failure treatment if survived can run into the 100s of thousands of dollars.
To which I received the following response:
- “After review of the appeal letter and the medical documentation, it has been determined that the Uvulopalatopharyngoplasty surgery will be a covered expense. Benefits will be payable according to the plan provisions and eligibility in effect at the time of service”
Thank you very much Mr Insurance Appeal Advisor Man. Thank you for eventually seeing my point of view. You have finally figured out that even YOU have the right to my opinion!
Thank you to everyone for the support and ammunition!
Now for the pain. 10 – 14 days of utter hell. Sheer unadulterated agony. At least it will have a very positive outcome and if nothing else, I won’t have to sleep on the couch anymore!
To be continued with “before and after” and perhaps some “during” photos…
