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Achilles is ruptured, but Fixer comes to the rescue

Updated: July 3, 2012 10:06AM



Dear Fixer: I injured myself early this year — I ruptured my Achilles tendon and had to have surgery to repair it. As luck would have it, I re-ruptured it 28 days later and had to have the same surgery to repair it.

I have Loyola University Health System as my network of choice and was glad to know they had acquired Gottlieb Memorial Hospital because this hospital is located closer to my house than their main facility in Maywood.

I had both surgeries at Gottlieb. During my follow-up visits, I was told that I would have to undergo physical therapy. I was excited about starting therapy — I just wanted to get back to normal.

My doctor’s nurse told me I could go to Gottlieb for the physical therapy. My primary doctor issued a referral and she entered it into Loyola’s electronic records system.

When I arrived at Gottlieb, they asked if I had obtained a referral and I said yes. Later, at my second visit, they told me my referral was not good at Gottlieb.

I was surprised since I had my two surgeries at Gottlieb and my insurance covered those. I am being stiffed with a bill of almost $1,000 for the physical therapy.

If you’re lost, Fixer, so am I. This is crazy.

Gilbert Villegas Jr., Chicago

Dear Gilbert: This did seem odd, given that Gottlieb’s own logo has that beautiful “1870” Loyola crest identifying it with the university’s brand.

The good news is once we brought it to their attention, the folks at Loyola got this fixed quickly. They found the referrals and processed your claims, and everything will be covered under your health plan. Loyola spokeswoman Stasia Thompson apologized for the mix-up and said she hopes you’re feeling better soon.

Another insurance snafu

Dear Fixer: I’ve been a subscriber to the Sun-Times in excess of 30 years and delivered it long before that!

Recently, I took a full-time job to get health insurance. The place was too small for group insurance, but the boss agreed to assist me with getting an individual plan through Blue Cross Blue Shield of Illinois. I submitted the application and he sent in the initial two-month check for $726.26.

The insurance company called me for a phone interview, which was somewhat brain-wracking as I had to recall occurrences of the past five years at the drop of a hat. The doctor appeared to have all the answers before he asked the questions. I answered truthfully and to the best of my recollection.

Two days later, I got a denial via email.

This upset me greatly for three reasons: Being denied electronically with no reason given, being grilled for minor items that happened over the past 60 months, and finally, having in my possession a “certificate of insurability” from Blue Cross Blue Shield.

I found out they denied me for having systemic lupus, which I have never had. I gave them a handwritten note from my doctor of seven years, stating that I have never had systemic lupus, with blood work having been performed to verify this.

Then they denied me for having discoid lupus.

I have sub-cutaneous lupus, or lupus of the skin. It is not debilitating. If the person takes some precautions with alcohol, smoking, staying out of the sun and attempting to avoid stress, you would not even know you have it. I am not “high risk.”

Neal A. Filipello, Crete

Dear Neal: Your letter is exactly why The Fixer cannot wait till the health care reform provision that will completely ban all pre-existing conditions takes effect in 2014. We talked to a rheumatologist we respect, and he said patients with subacute cutaneous lupus erythematosus typically don’t develop the serious kidney and brain issues that other lupus patients can experience. That’s especially true of people like you, who were diagnosed a long time ago (seven years, in your case.)

We thought perhaps your “certificate of insurability” would help, but alas, Blue Cross Blue Shield spokeswoman Mary Ann Schultz said that refers to your previous participation in a group plan and has no bearing on individual coverage.

They’re not budging. You told us your next move is to try to stay healthy and wait two years, when insurers will no longer be able to reject you for a pre-existing condition.

Getting the runaround over a consumer problem? Tell it to The Fixer at suntimes.com/fixer , where you’ll find a simple form to fill out. You’ll also find a list of consumer contacts and tips. Because of the large volume of submissions, The Fixer can’t personally reply to every problem. Letters are edited for length and clarity.



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