How Fraud & Abuse Contribute to the Health Care Crisis in AmericaDRAFT: For anyone who would like to know why I feel so strongly that any reform that does not address the issue of regulation, oversight and enforcement… perhaps my experience will serve as an example of how the judicial system fails to protect those who so desperately need help to fight injustice, inequity and corruption in the United States of America.
At 22 I was diagnosed with a degenerative spinal condition. Yes, there are times when the pain is so terrible, I cannot lifet myself out pf ed or tie my shoes. But far worse is having the knowledge that the level of damage to my spinal cord could have been stopped had I received adequate health care.
Yes, I had insurance. But who was there to make them pay???
14 years later, I finally received surgical intervention, and can feel my hands again— and as a writer, that has been a miraculous gift.
Through the toughest times in my life, no one told me I was wasting my time and money on an education I would never be able to use.
After all I just wanted a diversion.
Even more disturbing than the damage to my spinal cord, is the realization that I missed mosre than 14 years of my life. So not only did I waste my time and money on an education I will never be able to use, I wasted a window of opportunity. A moment in time when I almost had a world the world at my fingertips.
Without any real place to go after college, I felt I had no other choice than to become a professional student of sorts—you know, the ones who stay in school forever to take advantage of cheap housing, health insurance, and student loans.
Unfortunately, I wandered aimlessly through the system acquiring useless knowledge and letters after my name that do not mean jack in the real world. But it distracted mye from the fact that my spinal cord continued to worsen my physical and emotional health.
So with no prosepects on the horizon— and so thrilled thto feel my hands today, that the one thing I can do is write. So for now, I write, maybe tomorrow I’ll read, but if there is any justice left in this world, maybe someday I will actually live.
Despite having four individual insurance policies including a major plan with Blue Cross Blue Shield for $1,000,000; I still wound up on Medicaid, and eventually welfare and social security with a total income of under $6,000 / year.
The insurance investigators ultimately ruled in my favor, however I was unable to collect any damages for two reasons: Although mandatory federal fines in the amount of $560,000 would require legal assistance and complicated civil litigation that would be timely, costly, and emotionally traumatic. Second, under federal law, grants immunity to ERISA plans: a type of group insurance that is totally untouchable due to federal preemption of state law that leaves the beneficiary without recourse or the ability to collect punitive damages under federal law,
Unfortunately, this was a very complicated case that involved unscrupulous attorneys that involved tax and insurance fraud, and has yet to be resolved despite the overwhelming evidence of fraud and the favorable ruling from the insurance department. It should also be notes that no criminal charges were ever brought against any of the participants, which s even more disturbing if you knew the history of the parties involved, some were arrested for RICO conspiracy, Tax Evasion, Embezzlement, Extortion, and wire fraud. One man actually shot himself in the head one month after the Insurance Dept. opened the investigation.
So one is dead, one got off on a technicality, one was acquitted, and several others were never prosecuted. I however, pay a price for their crimes every day of my life, I now live in a prison of sorts: a prison of poverty, and despair with no real expectation of change on the horizon.
So here are the facts
I filed a complaint with the Pennsylvania Insurance Department in 1995, and received response six months after the policy had expired. Despite the considerable evidence I provided to the Insurance Dept. and Pennsylvania Blue Shield, I was told that despite the overwhelming evidence that I provided, the Insurance Dept. Did not have the authority to override the terms of the contract.
Since ERISA mandates that all beneficiaries (including insured dependents) be given a copy of the policy (among other forms of insurance identification, e.g., EOBs, Insurance ID C, and a copy of the policy, my requests for ERISA mandated materials were repeatedly denied until the Jason Manne from the Dept. of Public Welfare sent a letter to my insurance carrier to inform them that they in accordance with federal law, they must honor my request for a copy of the insurance policy.
Blue Shield refused to honor my request for COBRA continuation and / or a reassignment of benefits so those providers could be reimbursed directly. According to their attorney, Tija Hilton-Phillips, they had no obligation to provide me with any information about COBRA continuation and shifted the burden of responsibility onto the plan administrator and/or fiduciary. In addition to having the terms of my policy falsified in writing, I was unable to identify the plan administrator of fiduciary. Since federal law requires that all plans be filed with the Dept. of Labor, I contacted them on multiple occasions and wrote several letters requesting a copy of claims made under the policy, the plan fiduciary, administrator, and the specific type of ERISA plan (e.g., self-insured) that was on filed in accordance with federal law. Again, my verbal requests were denied. I then sent a written request to the regional office in Philadelphia but again, received no response.
Washington requests in Washington in accordance with federal law. , e.g., self-insured, their assistance in (with information Furthermore, the Dept. of Labor requesting this information were never answered. I never found out the name of the plan administrator or the fiduciary, and was never offered COBRA continuation, and then BCBS refused to let me continue under COBRA, claiming they were not obligated to offer it to… so who is ultimately held accountable in these situations.
When I first filed this complaint against BCBS, each agency denied responsibility despite the overwhelming evidence that I had provided. Although I was only 22 at the time, I spent my days and nights reading up on insurance, labor and employment law, and subsequently came to believe that aside from violating my natural rights, I had been denied due process protections and requested legal assistance from advocacy organizations in New York, Pennsylvania and Tennessee. I was unable to find anyone who would take my claims seriously, and could not find anyone to take my case pro-bono or on contingency. Eventually, I moved to Nashville, TN and tried to recover from the physical injuries and the new emotional scars that left me cynical and bitter about a judicial system that consistently fails to enforce natural and human rights.
Everyone I spoken to thus far reiterates the same statement— practically verbatim, “I sympathize with your dilemma, yet, as you know, our office does not have the jurisdiction to assist you in this matter.”
I sought the assistance of an attorney at Shnaeder Harrison years ago (regarding Pennsylvania Act 62) and Jason Manne in the Dept. of Public Welfare.
Although I may be biased, I believe this case has substantial social merit and long standing implications for children in the state of Pennsylvania. I am a reputable witness, and have 5 years of doctoral studies under my belt in the field of social policy.
I have been unsuccessful in my search for a competent litigator (unfortunately, this is an unprecedented case that touches on all the hot issues before the 3rd circuit including ERISA and the State’s interest in Equal Educational Opportunity and due process protections for children (and adults) who are “victimized twice… first by their parents, and then, again by a judicial system who fails to protect them” (it’s been a while, but I believe that is a paraphrase of the dissenting opinion from Justice Montemuro in Curtis v. Klein.
In many ways, I feel it is too late for me to recover what I lost due to a snag in the law and a few loopholes in the system. I have collected evidence for over 14 years because I used to believe that justice might prevail.
If she has an interest in looking bold into the face of police corruption, I would like to share my story (and the documents) to be sure no other child in the Commonwealth of Pennsylvania falls victim to such heinous crimes due to legal technicalities from an outdated piece of legislation. It has been 14 years since my case was “abandoned” by the state judicial system in the Philadelphia Court of Common Pleas. It is time to have these loop holes closed for good and ensure equal protection under the law for all children—not just those who are lucky enough to have a fair hearing or be heard before they reach the age of majority.
With the support and inspiration, I received from some very kind and brilliant professors in sociology and social policy, plan to submit a book proposal to document the sequence of events that still astound me and curious onlookers who take a quick peek as they casually pass in and out of my life. You see, it is much like a traffic accident— people like to take comfort in seeing the tragedy of a broken man and his family demonstrating the social injustices and inequity resulting from a stratified society where only “violent” criminals or those who commit acts that violate or impede the natural rights of others are not taken seriously by the judicial system or the public at large. Unaware of the consequences that arise from dual standards in the worst of academic snobbery and intellectual elitism — living a lifestyle they might otherwise envy.
I would appreciate assistance in restoring my social security number and account so that I do not have live in constant fear. If that means either relocating to another country and/or having my name and social security number changed or restored, it is probably well worth the inconvenience if it means there is still hope for living a peaceful existence.