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5 patients, 5 stories: Injured cyclist battles insurer

Arizona Daily Sun: 5 patients, 5 stories: Injured cyclist battles insurer


By CYNDY COLE
Sun Staff Reporter
Sunday, September 13, 2009

Firefighter, paramedic and bicycle racer PJ Lingley, 30, was riding his bike from Sedona uphill on Highway 89A in June, 2004, when he was struck by a car at Midgely Bridge.

The driver hit him, ran him over, broke his left arm and his left leg near the ankle, and didn’t stop. Lingley was flown to the emergency department of Flagstaff Medical Center, where he says he was "treated graciously and quickly."

"I was lucky, a broken humerus, tibia, and fibula," he wrote in an e-mail. "But no head or internal soft injuries."

Yes, "lucky."

The beneficiary of what he expected to be "top-notch" insurance through the Sedona Fire Department, he received surgery and was ready to return to work after 3 months.

He was healed after 4 months and some physical therapy, he said.

Then the next battle began.

The physicians who treated Lingley in the FMC emergency room were not in his plan’s network, meaning he was responsible for half of that bill until his deductible was met.

Altogether, with helicopter and ambulance, the medical bills came to about $38,000.

The vehicle driver was later found and had no insurance.

Lingley contacted his insurance company, signed an affidavit affirming he was riding a bike and that the driver was not insured, and Lingley’s insurance company said they would cover the bills.

He even provided the insurance company with a copy of the police report.

As the months rolled by, bill collectors began hounding Lingley.

"I had hundreds of collections notices," he said.

He came home off a 24-hour shift to a mailbox bulging with notices.

He called FMC and the doctors’ offices directly every week, offering to pay whatever portion he owed.

This wasn’t allowed, because he would end up paying more than his share that way, they said.

A year after his injury, the bills weren’t paid, and Lingley said he had had enough.

Aside from damage to his credit, it also wasn’t fair that those who treated him should go unpaid, he said.

"I then called my insurance company to relay my intent to sue for breach of contract," he explains via e-mail. "They blamed their lack of payment on the fact that I was injured by a vehicle and that his car insurance should pay. When shown the police report and follow-up report that displayed his lack of insurance they finally agreed to pay. I originally signed this affidavit right after the accident, but they stated they waited to see if something would ’pop up.’"

Lingley said his last bill was not paid by the insurer until 6 months after the accident. It took him even more time to write 50 to 60 letters to clear the collection notices from his credit history, he said.

"I ended up taking all the responsibility (for clearing his credit history) because there was no repercussion for the insurance company for not paying," he said.

Lingley is young, fit, and the perfect candidate for high- deductible or "catastrophic" insurance, he said.

A former advocate of private insurance, he said his failed to work when he needed it, leaving him supportive of a government- backed system to collect all fees and pay health care workers.

Anxiously waiting for Medicare

At 64, this Flagstaff woman went from full-time to part-time at her job, due to a cut in hours.

On condition of anonymity, she told her story.

"They started cutting our hours, and because I didn’t have enough hours to be full-time, they cut our health insurance," she said.

She received a notice in the mail saying she was no longer insured, and ultimately resigned to seek other work.

Her unemployment benefits total $950 per month.

Due to a history with a few surgeries, breathing apnea and another breathing problem, the woman doubted her ability to get private insurance, and opted to pay full-price to stay on her employer’s insurance for a limited time, known as COBRA.

It costs $660 per month -- 69 percent of her income.

"I had talked to some health insurance companies, and when I tell them some of the things that I have, like high blood pressure, that’s it. You’re done right there," she said.

She’s got what insurance companies would call "pre-existing conditions."

And she’s in the majority.

About 60 percent of everyone living in the United States over age 18 had at least one chronic condition as of 2005, according to data compiled by one office under the U.S. Department of Health and Human Services.

The woman is using parts of her retirement fund to cover her insurance bill, just waiting for the day she turns 65 and is accepted into Medicare.

"I’m getting by, but it’s costing me a lot to live like this," she said.

In all, about $8,000 to buy insurance until she turns 65.

Great insurance, future worries

Laura Shearin had her son in 2006, and he developed a life- threatening infection soon after that required an emergency flight to Phoenix and three surgeries on his leg.

"I cried in gratitude," she wrote, "as I opened over $200,000 worth of medical bills (the life flight alone, with ambulances, ran about $27,000), and realized that because I had good insurance, I was out of pocket only about $3,000. I really am grateful."

Shearin pays about $300 per month through her employer, a federal agency, for a $1,200 per month policy.

Her son is well, and requires only periodic check-ups to ensure the infection hasn’t returned.

But now he’s got a pre-existing condition, and she worries about ever changing jobs or losing coverage for his sake.

She had planned to retire early, but not anymore.

"I have to maintain this very expensive insurance, which by itself, prevents me from retiring," she wrote.

Shearin plans to spend the next 15 years with the same employer.

Major medical problems leave family broke

Peggy George and husband Frank are having some very tough years.

The two moved with their children from Flagstaff to Phoenix in late August, after Peggy lost her job (and her long commute) at a Scottsdale call center.

She has a blood disorder that requires expensive monthly tests, running about $600 apiece.

"The deal is, I need to be on blood thinners constantly and have blood work once, probably, twice a month, for the rest of my life," she said. "And basically, that’s been impossible to obtain."

Frank has severe depression, uncontrolled diabetes, a loss of blood to his extremities, a back broken in a driving accident, obesity, asthma, has had a heart attack, and has a degenerative disease attacking every disk in his spine.

At 53 he is bound for a wheelchair in an estimated two to three years, doctors told them.

Their family of four is living on unemployment and Social Security.

Peggy has a bachelor’s degree and once had a $70,000 per year job in management, before having children.

She has sent out about 1,100 resumes in the last few months, for jobs all over the country.

In recent years they’ve lived in Texas, Nevada, Vermont and Arizona, often moving to wherever they thought they could find better medical care and lower rent, Peggy said.

Peggy’s blood disorder has landed her in the hospital with blood clots in her lungs.

The average hospital stay in Arizona lasted 4.3 days and cost $31,937 as of last year, according to the Arizona Department of Health Services.

Peggy had pregnancy complications with each of two children, then requiring hospitalization and medicine to be taken multiple times per day at $500 per shot.

Then there was an emergency Caesarian section ordered by her physician, and an infection that required hospitalization again.

Medicaid called all of her pregnancy treatments medically unnecessary, even after her physicians went before the agency to argue they were urgently needed.

"Our experience with Medicaid is they don’t pay for anything," she said.

Health bills led her to declare bankruptcy in 2000.

She estimates she and her husband now owe between $2 million and $3 million again.

She has not been to the dentist in a decade.

Peggy’s last job offered health insurance, but it would have taken half of her minimum-wage paycheck to insure her family.

Free clinics sometimes help fill some of their prescriptions, but they often don’t have the testing equipment or specialists to truly help with their complicated problems, she said.

Private practices are typically unwilling to see either of the pair, knowing they are uninsured, and thus unlikely to order expensive tests needed for responsible care.

Their only option at this point, she said, is to turn to the emergency rooms for treatment, because these places are legally required to treat her if her condition is severe enough.

"If we get sick," Peggy said, "you can bet it gets pretty bad."

A charitable act gets expensive

Book author and river guide Michael Ghiglieri and his wife were walking around south of Flagstaff in mid-July when they came across a scrawny coyote pup lying on the ground, apparently sick.

He felt it was his duty to save it, even if an animal management person might advise otherwise.

"My wife is a rescue-everything kind of person," he explained.

He gave the animal some water from his canteen, then carried it like a baby for about 45 minutes while walking back to civilization, as it bled on him.

The vet, unable to do work on wild animals, euthanized it and sent it for rabies testing.

Noting a scratch on his arm, Ghiglieri called the emergency room at Flagstaff Medical Center that Friday night, asking if he needed to come in immediately to get a series of rabies shots as a precaution, or if he could go to the county health department on the coming Monday.

The person on the phone did not answer any questions and told him to come to the emergency room, where Friday became Saturday as he waited.

"By now, it’s 1:30 in the morning," he said. "You’ve been sitting there for three and a half hours. You get a little dumber."

The healthy 62-year-old has rarely had need for insurance or major medical help.

He has a catastrophic insurance policy with a $7,500 deductible.

He asked the ER staff about costs, and whether the shots were needed, or needed that day in that department.

"I told the physician, twice: This is out of my pocket. Are you sure I need it?" Ghiglieri said.

He expected a "ridiculous" bill of $1,000 or $2,000.

The physician billed him $159 for administering the injections.

Then came the bill from the hospital: more than $10,500, including $8,500 for one injection of a plasma-based treatment that he was told was crucial before he could have the series of anti- rabies shots.

"Not only am I annoyed with it," he said of the bill, "I think it’s astounding."

He took the bill to the hospital’s billing department, where he spoke to a woman sitting behind a glass wall.

"You see where it says $8,500 for one shot?" he asked her. "Does that seem to you to be a reasonable, appropriate amount of money for a shot?"

The woman said she would send the bill to an employee charged with reviewing appealed bills from patients.

He asked for that employee’s phone number.

No such luck.

FMC says such treatment is not normal.

"That would certainly seem to me to be an anomaly," said Dale Pugh, vice president of marketing and public affairs for FMC.

Two weeks after requesting someone review his bill and get back to him, Ghiglieri said he had received no phone call.

The Coconino County Health Department would have referred him back to FMC for the pre-anti-rabies shot if he had arrived there earlier.

An administrator at a UCLA hospital in Los Angeles said their emergency room and urgent care charges $600 for that same preliminary shot.

And the Arizona Department of Health Services put the cost for the shot alone at an estimated $700.

Pugh declined to answer questions on FMC’s cost or charges for the one treatment, saying the pricing process was too complicated considering the rate at which vaccinations expire, handling costs, other emergency room costs, and regulations involved.

The euthanized coyote tested negative for rabies.