Denied: My Battle Against Big Healthcare

By Scott Reddoch

It must have seemed so easy, like taking candy from a baby. The denial letter almost guaranteed my death. It read: “Mr. Reddoch, Our staff doctor has reviewed your request. The items requested have been classified as medically unnecessary and is denied. If you feel this decision is an error, you can appeal it within 30 business days of the date of this letter.” Certainly there had been some mistake, how could a doctor deny me, of all people a wheelchair? Nobody wants a wheelchair, but need one for mobility. I was no exception. My family and my team of medical professionals started assembling the appeal. Everyone agreed that there must be some error, denying a wheelchair was absurd.

Building the Appeal

We made a “sturdy” appeal that left no doubt that the decision had been reached in error. I included letters from my general practitioner, neurologist, and physical therapist. The vendor that was to get me the chair combed through the request for any coding mistakes. Pictures of me were also part of it. Everyone had a final review of the appeal and it was sent via postal service per the instructions. A couple of weeks went by and we heard nothing. Nervous about the situation my mother called to ask if they received it. After the usual maze of transfers, she finally got a human. Frustrated, she calmly explained the purpose of the call. The person informed her that it was not received and given a number to call the legal department.

The Fax Machine Fiasco

The next day, the legal department was called and that is where this circus gets really good. Luckily we had copies of everything in the appeal, their attorney will handle the appeal moving forward to make sure no document was lost again. That was great news. Then the shoe dropped, my mother tells this attorney that we have copies of the appeal and she can email it right away, then the attorney says “you have to fax it.” What was probably the largest insurance company in the US uses a fax machine for this.

I don’t know about you, but I haven’t used a fax machine in 20 years. I wasn’t sure that I knew anyone with a fax machine. But my life depended on getting legal what they needed. One of my mom’s friends had a fax machine at her business. My mother printed all of the appeal, checked that everything was there, and drove off to fax it. This certainly took some work, but she got it all faxed.

The next day she calls the attorney to check that the fax was received. The attorney acknowledged receiving the fax, but said that she didn’t need all of the fax and that she would mail us the single page appeal form. After a few days we get this simple form which is filled out and faxed over. It gets better.

The Second Denial

About two weeks later I get another denial letter. “Mr. Reddoch, We reviewed your appeal and still consider your request to be medically unnecessary and is denied. If you desire, a Judge in your state can make a final ruling. You may incur legal fees and be required to pay court ordered fines.” This was a good time to be non-verbal because I had a lot to say about the letter.

I was floored. All of that effort, and all of the people that worked on the appeal was a waste. I thought that there had been a mistake, but quickly learned that this wasn’t about my need, it was about money. This changed me from “Appeal Scott” to “Battle Scott.” Regardless of their statement of risk, I decided that a Judge would need to see this. I don’t know anything about healthcare or legal proceedings, but I know how to fight. This was finally becoming a game I can play.

Taking It to Court

There was an application filed with the state court. There were instructions to provide any documents that you want the judge to review. It may have been overkill, but I sent the entire appeal. A hearing was scheduled for about 90 days from the application’s filing.

The Intimidation Letters

Shortly after, I started receiving letters from the insurance company (I got three in total.) “Mr. Reddoch, Currently our legal fees are $5,700.00 you may be required to pay that and additional court fines based on the judgment of your hearing.” This letter struck fear in my parents who take care of me, but it energized me. I remember doing dumb kid stuff and somebody saying “don’t look down” as you climb high in a tree.

The second letter was just like the first one, but not the third. Letters one and two were mere appetizers, letter three was the main course. Letter three was the ruler of letters, designed to strike fear into any unfortunate recipient. It read “Mr. Reddoch, This letter is to inform you that we currently have a total of $11,300.00 in legal fees that you may be required to pay as well as any court fines. To ensure that you are aware of all of your options, we propose to waive all legal fees upon cancellation of the hearing. Page two of this letter details the steps for cancellation. Thank you.” Oh boy this was a good one. Lots of people see different things in this letter, I think they are scared. They never close with thank you. I got them right where I want them.

Preparing for Battle

I don’t think that anyone on my team had any experience with a Judge. Lack of experience and all, we prepared for the hearing. We even had a rehearsal to practice who says what. Everyone studied the appeal and watched some lawyer movies to get ready for the big day. We didn’t have a clue of what lied ahead, but we were a prepared bunch.

The Hearing

The hearing date arrived. Due to the pandemic the hearing was remote and all via telephone. The insurance company was represented by two attorneys and the doctor that denied me a wheelchair. Our team consisted of my mom, physical and speech therapists, manager of the company who is getting me the chair and me. The judge asked that we state our names. I was asked a few more questions and the judge patiently waited while I frantically used my computer voice to answer her questions.

She turned to the insurance company and asked them what were the reasons for denial. They had some silly comments, but concluded that this chair was not necessary and they would not provide that type. The doctor explained that I was requesting something in excess of my need. I’m still not clear on what condition would qualify in her mind, being non-verbal and quadriplegic wasn’t it. The judge then turned to me. We were ready. I first called on the manager who explained that the chair requested fit their guidelines for a chair for me and was coded per their instructions. The doctor concurred and we realized that she had not read anything that I had sent. This was looking good until the insurance company’s lawyers threw a wrench in the operation. They questioned the original request and said that they wanted a professional opinion of my request for that particular chair. Hehehe, we had rehearsed this one. My physical therapist Penny then introduced herself and says “I have a doctorate in physical therapy. Am I considered a professional?” They concur that she is a professional. Then she says “I wrote the request.” The judge says that she has heard both sides and is ready to make a decision. The judge rules in my favor and orders the insurance company to approve my request. I guess taking this candy wasn’t so easy.