Parents Lost Their Daughter to a Heroin Overdose & Fought United Healthcare For Denying Coverage For Treatment
It’s hard enough on parents to have a child with a heroin addiction. But imagine losing your child to a heroin overdose while having to fight your insurance company because they refuse to cover addiction treatment and abide by the 2008 Mental Health Parity Act? Well for Don and Sally Vail of Stonington, Connecticut, this is exactly what happened.
Don and Sally wasn’t aware that their daughter Maddie has a problem with heroin addiction until they received an “explanation of benefits” from their insurance company related to her stay at a drug rehab center. Maddie, only 19 years old had checked herself into a facility with the help of a family friend. She had only told her parents that she was going away for awhile.
According to the most recent U.S. Surgeon General’s report on alcohol, drugs and health, Maddie is one of the 27 million plus Americans who use and abuse illicit drugs. Maddie was among the lucky 10% to receive addiction treatment. She started out getting help on her own to avoid disappointing her parents. However, her parents were very supportive and joined the effort to help her as soon as they became aware of her drug problem.
Regrettably, their two-year battle with their daughter’s heroin addiction ended in tragedy when Maddie died of a heroin overdose at 21 years old on January 23, 2016. Don and Sally has been fighting their family’s health insurance carrier and against a society that discriminates against addicts for the last 2 years. In 2014, addiction claimed the lives of an overwhelming 28,647 Americans due to a fatal overdose from either heroin or some kind of opioid pain reliever pill. Because of the staggering 2014 death toll because of the opioid epidemic, lawmakers set aside $1 billion for the states to fight against it, thanks to President Barrack Obama signing the 21st Century Cures Act into law on December 13th, 2016.
Maddie was a talented artist and cook but also suffered from dyslexia. She graduated high school but never enrolled in college. Maddie became somewhat withdrawn and cut the lines of communication. She’d spend more time in her room of a five bedroom house she shared with her parents and siblings overlooking Little Narragansett Bay, painting each wall a different color.
Don and Sally felt uneasy and suspected she may be smoking marijuana. But they didn’t press the issue. Don said, “If you have an uneasy feeling, don’t ignore it.”
United Healthcare Insurance Denies Addiction Treatment Claim
The first drug rehab facility Maddie visited was within her insurance plan’s network. Thus, her carrier covered the entire amount of her treatment. Regrettably, Maddie started using again and overdosed on heroin soon after departing the treatment center. She has spent four hours in the emergency room before the hospital discharged her. Sally said, “She shouldn’t have been tossed to the curb.”
Don and Sally Vail then admitted Matty to Caron Center in Wernersville, Pennsylvania. This drug rehab facility wanted $32,000 upfront to cover the first month’s of treatment – a practice that’s not uncommon since many addiction treatment centers can’t count on getting money from the patient’s insurance company. Thus, the Vails borrowed the money from a relative.
Maddie did very well at Caron Treatment Center, but the facility was out-of-network for her health plan. A 20 day stay at Caron came to $34,186. As per regular practice, Caron submitted the bills to the Vails’ insurance company United Healthcare in hopes that the family could at least get reimbursed for Maddie’s addiction treatment at the lower, out-of-network rate.
Regrettably, the claims were denied on the grounds that the Vails did not receive a “pre-certification” for Maddie’s stay. According to Don, there was no time for paperwork and Maddie’s parents had to rush Maddie to Caron after her overdose and an unexpected, fast discharge from the hospital.
A United Healthcare spokeswoman stated in an interview, “We try to assist members in better understanding their coverage options and, if necessary, their appeal rights. We sympathize with the Vail family for their terrible loss.”.
But sympathy wasn’t enough as United Healthcare left the Vails with a hefty bill and in significant debt. The Vails appealed the insurance company’s decision but it was denied again, this time based on “lack of medical necessity”.
Maddie clearly needed help, but sadly, this type of denial is relatively common when it comes to mental health claims. In fact, according to a 2014 survey reported in JAMA Psychiatry, 29% of patients reported having a mental health claim denied based on medical necessity versus 14% of patients for medical claims
In 2008, Congress passed a law (Mental Healthy Parity Law) that aims at preventing insurers from treating mental health claims any different than purely medical claims. But these types of denials clearly demonstrate that insurance companies are having a problem following the law. The 21st Century Cures Act just passed on December, 13 2016 contains provisions that are supposed to enforce this law.
When asked, United Healthcare claimed they followed “independent evidence-based guidelines” in setting coverage parameters.
The Fight Against Their Insurance Company
The Vails decided to fight against the insurance companies denial. Don used to work as an insurance broker, advising small to mid-sized businesses on health benefit design. Claims however, are a different area and thus, the Vails needed some additional help with the appeal. “Not many people are equipped to deal with insurance on that level – we’re out of our depth,” Don said.
Appealing denies isn’t easy and insurance companies “count on attrition”, said Don. “They count on wearing you down.”
The Vails decided to hire an insurance appeals advocate at MedBillsAssist named Katalin Goenz in Stamford, Connecticut. After fighting for over a year, United Healthcare did end up paying most of the Carol Treatment Center bill. Goencz also helped the Vails recover approximately 40% of the cost of Maddie’s three month subsequent stay at a “step-down facility” (a facility that provides less intensive care) according to Don. Goencz reports, in appealing mental health claims, “you need to address why the patient is there for so long.”
Both heroin and addiction rewires the brain and alters it both chemically and structurally. Addiction affects and disrupts the way an addict thinks and reduces cognitive functioning while increasing the body’s tolerance. Even after substance abuse stops, evidence suggests that these changes in the brain persist for quite some time.
It All Ended in Tragedy – Maddie’s Heroin Overdose Death
Regrettably, Maddie couldn’t stop in the end. Don said, “she wanted to quit, but it had her but the scruff of her neck.” She lived for three weeks on life support after the overdose that ultimately killed her.
United Healthcare covered all of Maddie’s end-of-life care, which was more than double the total of her addiction treatment bill. Don sadly stated, “The cost of dying was much more expensive than the cost of treatment.”
As devastating as the whole ordeal was, Don and Sally included Maddie’s cause of death in her obituary. “Addiction carries an unfair stigma”, the Vails wrote. To this day, society still stigmatizes addiction and still has a problem recognizing addiction as a disease, despite the fact that it has been declared one by the American Medical Association (AMA), Substance Abuse Mental Health Services Administration (SAMHSA) and other well respected medical organizations and associations. Don said, “We are losing the war against drugs. I have enormous empathy for anyone battling this disease.”
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