Coverage of Medical Treatment Questioned: Patient Receives Bill for $17,000 Despite Insurance Promise of Coverage
Retiree Faces Financial Struggles Due to Insurance Dispute
Kevin Danahy, a 60-year-old retiree from New York, is currently embroiled in a dispute with his progressive insurance provider, Leading Edge Administrators, over coverage for essential treatments. Danahy suffers from cardiac sarcoidosis, a heart condition that requires regular infusions of Remicade, a costly drug.
In March, Danahy's access to Remicade was endangered when his wife's health insurance provider switched to Leading Edge Administrators, a private insurer with a history of unpaid bills, lawsuits, and shoddy coverage. Danahy was initially approved for seven Remicade treatments over the next year by Anthem, but later received bills for the full cost of the treatments, totaling $17,000.
The reasons given for the unexpected bills included lack of pre-certification or the medication not being covered under his medical plan. However, Danahy was initially told by Leading Edge that Remicade wasn't covered by his plan, despite a letter stating otherwise.
Danahy skipped his scheduled August infusion due to concerns about being charged thousands more by Leading Edge. After weeks of effort, he received revised statements showing he owed only $1,451 for two treatments, following a threat of legal action.
Stellar Health Group, Danahy's wife's former employer, ended her employment due to subpar performance and failure to adhere to proper procedures. Danahy suspects this decision was made to avoid paying for his future treatments. Stellar Health Group denied that the decision was related to Danahy's medical condition or related healthcare costs.
The insurance responsible for Danahy's treatment is not specified in the available information. Danahy is applying for a plan that does cover infusion treatments. However, he will now rely only on Medicare, as his current plan doesn't cover infusion treatments.
Danahy expressed concern about putting a financial burden on his family and would rather pay for his daughter's wedding than his infusion. His next treatment is scheduled for October, and delaying it could cause his condition to return and threaten serious consequences for his health.
Leading Edge did not respond to questions for this story. Public Partnerships, LLC (PPL), the CDPAP provider, has stated that it is speaking to insurance brokers to provide better services by the end of 2023. PPL's health plans offer limited coverage for prescription drugs, with one plan offering no coverage at all for most drugs.
This dispute highlights the challenges faced by individuals who rely on insurance for critical treatments, especially when dealing with private insurers with questionable track records. Danahy's case serves as a reminder of the importance of transparency and accountability in the healthcare industry.
