Julie sent a message to Jay M. Gellert – President and Chief Executive Officer of Health Net, Inc. – Email Address that said:
Dear Mr. Gellert,
I am writing to you in plea for help with my coverage. My situation is very complicated so bare with me on my story. My husband and I decided to start a family and so I stopped taking birth control tablets but months went by and no sign of my menstrual cycle. I quickly made an appointment to see my PCP where she referred me to a OBGYN who then referred me to an Infertility doctor. I saw Dr.Kornafel where she took an ultrasound and blood work. She gave me a call and said my blood work was normal. I went on for a few months to see if my cycle would come back which it did but not consistent and much much less than before. I decided I needed to see her again so I made an appointment but 3 days before my appointment she changed the time on me twice! I can not keep changing my time off from work this often. I decided I needed a new doctor. I called my PCP to refer me to a different doctor, where they told me she is the only one in my group under HMO and to call my insurance. I called Healthnet and told the representative my story and for her to help me find another doctor or options. I didn't want to change my medical group because I like my PCP but would have had I known all this would happen. The representative told me I can use my PPO portion of my plan and she can send me a list of the covered doctors. So I did my research and picked Dr. Dumesic from the group and made an appointment. 2 months later I went in for my first appointment, payed my copay, everything went well. I was hopeful Dr. Dumesic had a much better plan and chance to start a family. When I got home I received a phone call from the office telling me my insurance wouldn't cover it. Freaking out, I call right away explaining my situation. How could it not be covered when the rep told me it was? This rep, I believe her name was Cindy told me it was not but I can submit an request for approval through my PCP to my HMO. Trying to get some answers I asked her how likely is that?? I need to know now because my next appointment was in a few days. Cindy trying to help, called my health group -Healthcare partners IPA who told her that most likely it will be approved because there was only one doctor in my HMO. Some relief, I call my PCP right away and had her submit an approval. I still went to my second appointment believing it was going to be approved. A week go by and I find it out it was denied. I call back and they tell me I need to submit an appeal from Healthnet. So I call your company again telling the representative (Jerry) my story and he tells me that my PPO is the one to cover it not my HMO. I am so confused at this point. I had to run to a meeting and so I asked him to call me back. He said he would do some research with my doctors office about this mess and call me in the morning. When he did not, I called again who I talked to Barbra. I had to explain myself again and she tells me that the doctor is not even on the covered list and that Healthnet would not cover any of it. I kept telling her but I got it off the list that Healthnet sent me (I still have that email). It escalated to senior advisors who she only spoke with and came down to suggesting I put in an appeals/grievance. She helped me put in the order and today, I get a phone call from Gus the appeals manager, I tell my story again letting him know I would never have gone to Dr. Dumesic had I known my PPO does not cover it. The representative lead me to believe it was covered. I even asked him to review all the calls before making his decision to deny my request. He said its been denied and he will listen to the tapes but it won't change the outcome. He just wouldn't hear me out or have any kind of sympathy to my problem.
My question is, why did the representative tell me these things? I rather have had her tell me "I don't know" rather than "your PPO will cover it" and "They most likely will approve". I understand it is my responsibility to read every aspect of coverage but wow who reads all of that or understands it even. I looked to your representatives to guide me and I wish I hadn't because they guided me in the wrong direction.
My last question is would you please help me, there must be something you can do for me. I'm only asking you to just get these two appointments covered. I won't even see Dr. Dumesic anymore since he is not covered. I really don't want to be responsible for these medical bills and I feel like I should get the chance for your company to cover it due to the conversations I had with your reps. Mr. Gellert I beg for you to listen to my conversations with the reps and decide for yourself if it was all in my wrong doing of going to see this Dr. Thank you for reading my story.
