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Re: [IP] Another new endo, another frustration (long)

     Around here I'd be looking for a lawyer or two as well as some new

> doctors. This sounds suspiciously like they are trying to "pad their
> income" by getting you in worse shape, so you'll need more visits...

Randall, your response to Janine provoked me to send this.

I've spent the last 2 days on the phone with the insurance and the doctor's
office trying to get :  a).  pump supplies & humalog  b).  aphacic contact lenses
which replace my lenses removed when I was a kid for cataracts and without which
I am legally blind and 3). access to my endo and the only doctor in town who does

The insurance company and the medical group they contract with and us all agree
that these things are covered by our policy and that they are responsible for
supplying them.  However, actually getting them is another story.  We have
managed care (I know the problems with this are not yet as severe in other parts
of the country) and no access to non managed care policies (this one is through
my husband's employment).  I started trying to get pump supplies and to see the
doctor in May.  I started working on the contacts 2 months ago (they have to be
replaced every 3 months).  Every single time I need contacts or supplies I go
through huge numbers of phone conversations and letters and etc trying to get the
system to provide them.  I'm a teacher and b/c of state hiring policies, I'm once
again working part-time at 3 campuses, covering 70 miles and have no phone access
most days of the week so the phone calls pose a real problem.

I'm getting desparate b/c of the number of times everything gets messed up.  I
don't know how to make them responsible for doing these things in a timely or
affordable manner -- can't seem to get this across.  Our Primary Care Physician
who we hardly know is exhausted but trying to help and has suggested we get a
lawyer.  We can't really afford to go to court, but I'm thinking about tactics to
pressure Aetna/US healthcare and the local medical group into being more
responsive.  They do have a grievance procedure but it takes 9-12 months to get
results and I needed lenses 2 weeks ago and pump supplies at the end of the week
so I can't wait that long.   I really just want to get stuff done more
effectively, not to start a war but from what I keep hearing from the doctors the
system is very broken.  Health care seems to be as "stuck" as those of us in
higher ed are and I've learned from that the only way things change is if you get
brave enough to quietly and persistantly insist that the situation needs fixing.

Does anyone know or understand the legal ramifications of their sloppiness?  Is
legal recourse really a good idea?  Would love some input!   This may effect all
of us down the line since California is being used as a model of managed care for
the eastern, mid western and southwestern states.


Insulin-Pumpers website http://www.bizsystems.com/Diabetes/