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Patient Fights For Care, Avoids Paralysis
Advocate Helped Turn Tragedy Into Triumph
POSTED: 12:44 pm MST November 2,
2009
UPDATED: 3:09 pm MST November 2,
2009
CENTENNIAL, Colo. -- Having health insurance does not guarantee the best or most rapid care.Bruce Stuckey learned that quickly when he was diagnosed with a life-threatening and extremely rare condition."It was not only growing, but invading my bones," said Stuckey.
At first, Stuckey said he did not know what he was dealing with in his spine. What doctors first thought was a cancerous tumor turned out to be a vascular anomaly."We discovered it was aggressive, destructive. We needed to do something about it. It needed to come out," Stuckey said."It" is an entity that forms before birth from blood vessels that are not reabsorbed during fetal development.Rarely, people are born with a vascular anomaly and specialists say, depending on where it is and if it grows, it can pose a serious risk."When you're watching someone you care about circle the drain, you just go into war mode. I have never been that angry or focused," said Kassidy Hill, Stuckey's former wife.The couple teamed up again to face what they said were horrendous circumstances."I prayed a lot. He prayed a lot," said Hall.Over a six-month period Stuckey learned the anomaly was growing rapidly, invading his spine, and would paralyze or kill him if it was not removed."It's a very rare entity. I think I'm the only doctor in the United States who's only committed to this one entity," said Dr. Wayne Yakes, a vascular malformation expert.Stuckey said his spine surgeon stabilized his spine and referred him to Yakes to have a procedure called an embolization to remove the mass.The couple said Stuckey's insurance, Pacificare, paid for several visits with Yakes leading up to the procedure."He was under sedation when I got a call from Dr. Yakes office saying that they had been denied to do the embolization," said Hall. "At that point I got really angry.""I didn't know where to turn and Kassidy started calling," Stuckey added."We went to war," Hall said.She said because Pacificare had been paying claims for Yakes, they assumed he was covered.When they learned he was not in their insurance network, time was of the essence and they reached out to the Call7 Investigators and anyone who would listen for help."I felt that people who were completely out of touch with me and my urgent situation were looking at a notebook and just deciding, 'Don't know this guy but let's turn him down,'" said Stuckey.He appealed Pacificare's decision because he was committed to having Yakes, a world expert in vascular malformation, do his surgery. He was denied again."'Pacificare has determined that your request does not meet the definition of time sensitive,'" said Hall, reading from a notice the couple received after making their appeal."Where would you say the nearest physician is who does these procedures with the regularity that you do?" Call7 Investigator Theresa Marchetta asked Yakes."No one with that regularity," he said. "I know some who may do 100 to 250 cases a year, which I think is tremendous. I do 1,000 a year."The couple said Pacificare would not return calls or explain their decisions and continued to stall, despite appeals and evidence from Stuckey’s physicians his situation was dire."Could he have been paralyzed?" Marchetta asked Yakes. "Oh, yes," he replied."They told us we would have 120 days and I politely reminded them that Bruce would be dead in 120 days," said Hall.Just days away from sure paralysis, Stuckey was finally referred to an in-network surgeon by Pacificare, in spite of the urgency, through a letter in the mail."I think because you rattled a few cages up there it got us the attention we needed," said Hall.Pacificare said in a statement to the Call7 Investigators:"Mr. Stuckey received care in a timely manner at the University of Colorado from a well-qualified specialist," and admitted that "several claims from Dr. Yakes were inadvertently paid.""If Pacificare's only reason for denying Dr. Yakes was to save money, they saved no money. By the time we got to that level, there was standing room only in the operating room at University Hospital," said Hall.She said because Stuckey's condition had deteriorated, the surgery required additional specialists and critical care.Ultimately, Stuckey said the surgery was a success and he is making great progress in his recovery. But he also said he could not have fought on his own and would not have had the same outcome without his personal advocate by his side."I'd have ended up in a nursing home, no doubt about that," said Stuckey.Hall said she does not want any credit, she just wants insurance companies to put patient care ahead of their bottom line."In our case it was a happy ending. But what about those families that it doesn't have a happy ending for? This is not a cost-saving measure," she said.The Colorado Division of Insurance investigates concerns about insurance. They give companies a deadline to respond and will levy fines if necessary.The fines are for what's called "market conduct violations" a term used to describe a situation when an insurance company is accused of not providing the coverage that was paid for.United Healthcare was fined $457,000 this month for violations in 2007.Kaiser Foundation Health Plan of Colorado was fined $201,000.To find out more about insurance regulations and consumer rights, visit Colorado Department of Regulatory Agencies.
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