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  • insurance, fmla and a compressed cord

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    Old 10-28-2009, 05:05 PM   #1
    happynessa
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    Question insurance, fmla and a compressed cord

    Apologies in advance for my wordy post! I have a large central disc herniation at C3/C4 that has flattened my cord and compressed it down to 6 mm. I have very little pain and only a little numbness in my right foot and toes and then I occasionally have burning pain and numbness down my right arm. Also both hands occasionally tingle. I have neck pain on occasion. Otherwise I'm not really in the sort of agonizing pain you would expect for my degree of compression. Even so, the radiologist that I work for and a neurosurgeon both have stressed to me that I am at risk for paralysis if I have an accident or fall awkwardly, etc. I'm sure you've heard this before and I know it does happen. The neurologist also seems to be a bit concerned about some of my reflexes being vigorous. I have positive hoffman's sign, etc.

    I have been scheduled for surgery on Wednesday, and have resigned myself to going through with it but here's the rub. I've only been a full timer at my job since April so I don't qualify for fmla and I am still in my pre exisiting condition waiting period. I don't know if this qualifies as pre existing but obviously this did not happen over night. I have congenital fusions in the three vertebrae below the herniation and the herniation is due to hypermobility. That said, I have NEVER been to a doctor for my neck but we all know how good insurance companies are at getting out of things. I'm afraid that when they see the word "congenital" they will play the preexisting card. My family and the neurosurgeon and the radiologist I work with are all urging me to hurry and get the surgery but I am afraid I will lose my job if I do and wind up with no insurance to boot! What a dilemma to be in! I could wait til April and not have any trouble with FMLA or with insurance. I would get to keep my job. But then what happens between now and then if I happen to get in an accident. My radiologist tells me this is potentially life threatening since your diaphragm can be paralysed at the C3/4 level.

    My director assures me that she will not give my job away but she is just a cog. There are so many others around her that could hire someone else in my place. There is no end of people waiting in line for a job in these troubling times. So when I should just be worrying about getting this surgery done andn getting better, I have instead to worry about my job and how I will pay for this if my insurance does not!

    Any suggestions, stories, would be very much appreciated! Do I really need this surgery so urgently? Could I get by with a neck brace til April?

    Vanessa

     
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    Old 10-28-2009, 06:36 PM   #2
    Toonces1
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    Re: insurance, fmla and a compressed cord

    Vanessa, sorry about the bind you are in. Many employers will offer a personal leave of absence when an employee needs to take time off work but does not qualify for FMLA. I would try to get an answer for this asap, and whatever is decided, I would ask for the decision in writing. Also, you may want to check out your state's fmla-type laws. Some states have FMLA-type leave laws that are even more generous that the federal FMLA law and may even kick in earlier than the federal 12 months.

    Others may have more advice about the insurance question. For a problem as serious as this, they should be able to review the pre-authorization for your surgery within about 3 business days so you can know early next week if it is approved or not. Doctors can often be instrumental in how they word things, justify the need for surgery, etc.

    GOOD LUCK. I hope it all works out well for you.

     
    Old 10-28-2009, 07:06 PM   #3
    happynessa
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    Re: insurance, fmla and a compressed cord

    Toonces1 Thank you for your post. They do offer personal leave but there is no protection for my job. They can post it and hire someone else if they want to. I think my immediate supervisors would never want to do that because I show up on time, do my job and don't make waves.

    That is a good point about mentioning the insurance coding and wording to the dr. I think he would be on board since he is pushing me to have this surgery. He clearly thinks it is important since I heard him telling his staff to move patients from next week's schedule to make room for me.

    I have lots of work to do tomorrow to get all this organized.

     
    Old 10-29-2009, 02:17 AM   #4
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    Re: insurance, fmla and a compressed cord

    What a situation. I have some advice but need to come back tomorrow from my computer.

     
    Old 10-29-2009, 03:00 PM   #5
    jennybyc
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    Re: insurance, fmla and a compressed cord

    Hi nessa....I was also down to 6mm at several points and still was able to wait 8 months to have my surgery.

    I had similar symptoms to you but worse. You don't have pain because the cord doesn't hurt. I had no pain when I had my surgery. My only symptom that I had a problem was going numb from the neck down after shoveling the driveway after a snowstorm. Then I found out about all the numbness and hyper reflexes and the staggering gait and the clumsy hands. I thought it was from my diabetes.

    Let me give you the stats I was given by my neurosurgeon. You have a 3% chance of becoming paralyzed if you get whiplash or have a bad fall or do something to aggravate your neck so badly that you cut off the blood supply to your spinal cord(that is what they worry about...no blood supply). BUT, you also have a 3% chance of the same thing happening during surgery. As a result, some docs will wait until your odds are actually greater. I had one neurosurgeon turn me down for surgery telling me to wait until I was 5mm or less.

    But I took my time finding the right surgeon and the right hospital. I wasn't going to be rushed into anything since it appeared I had time. So my neurologist made the following suggestions. Get a soft collar and wear it when driving(or all the time) to stop any whiplash you might experience. Your neurosurgeon might order a hard collar and that would be even better but you aren't supposed to drive with a hard collar on. Start eliminating any task that might cause you to fall....get lazy. Move throw rugs so you don't trip on them. No heavy lifting...preferably no lifting at all. And the hardest of all....don't look up. Sounds easy but it really is hard to remind yourself to not look up.

    You are looking at over $25,000 worth of surgery in all likely hood and that is a lot of money for your insurance company to try to get out of.....and they will try. And although your boss says your job is safe, get the FMLA anyhow.

    If you are careful with your neck, you should be okay until April and then you don't have the added burden of the financial problems. You don't need the stress.

    I know your docs will probably disagree but if told they might not get paid, they may decide to help you with the delay instead of pushing you. Just tell them straight out that you suspect you will be hit with pre-existing. A good surgeon will work WITH you and not against you.

    So if I can wait with 3 areas of 6mms for 8 months I think you can wait for 5-6 months with 1 area.

    Does that help?

    gentle hugs..................Jenny

     
    Old 10-29-2009, 08:56 PM   #6
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    Re: insurance, fmla and a compressed cord

    Don't worry about the word congenital as they have to base decisions on pre-ex ont the contractual language in the policy. Being new to the coverage the insurance company will likely review any potential pre-ex related conditions. So a broken arm from playing hockey yesterday won't trigger a review for pre-ex. But a spine problem, kidney problem, knee problem, blood disorder, etc will trigger a review for pre-ex.

    Did you have employment (or did a spouse) with insurance before this job? If you go from one group health policy to another without a break of more than 63 days then pre-ex doesn't apply. When you leave an employer's coverage the insurance company will send you a "Certificate" that shows the beginning and end dates of coverage. This is helpful when you've not had a gap and just need to prove it.

    You should immediately ask your HR/Benefits staff for a copy of the medical insurance policy and it will outline pre-ex provision and guidelines for you.

    Each health insurance company has its own rules regarding the waiting time before they will pick up a pre-existing condition on the policy, as well as how many months or years they will go back into your medical history in determining if something is a pre-existing condition.

    If you did not have prior group health coverage or had a gap of more than 63 days then pre-ex may apply. Usually the pre-ex is considered for any treatment within the first 12-24 months from the date coverage begins (all policies differ on this, 12 months is most of what I've seen). When you undergo any treatment the insurance company will ask you to prove that the condition is not pre-existing. During that time period you must have had no treatment for the condition or anything similar. Treatment includes, but is not limited to, any consultation, treatment, medication, or any other care for the condition for which you are seeking treatment.

    It gets tricky....let's say you went to your doctor 8 weeks before your job started for a cough. In your conversation you mentioned "my neck has really been aching lately". If that's in the records it can be deemed pre-ex.

    However, I will tell you that a few years ago I had knee surgery. I had only been an employee of the company for 8 months. And although it was just an arthroscopy I expected they'd ask me for my Certificate of Coverage from my prior health insurance. Nope. They never asked and the claims were all paid without question. I was surprised since although it was less than $3000 total I figured they'd ask!

    Let me know if I can be of further assistance.
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    Rt thumb fusion '13. R&L thumb arthroplasty '12 ; RT TKR & Bilat CTS' 11. Fusions: L5-S1('87), L4-S1('93), C5-C7('06), L3-S1('10), C4-C5('13). C5-C7 foraminotomy '08

     
    Old 10-30-2009, 02:08 AM   #7
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    Re: insurance, fmla and a compressed cord

    Hello again. The other posters made some good points. You didn't say how large your employer is but with some companies over 1000 employees there are many possibilities to your situation. In your hospitalization pre-certifcation it would be easy to get an answer on your coverage levels for this surgery..
    FYI - I have congenital central canal
    Stenosis yet it has never even been mentioned by my insurers ever.

    Could you wear a brace-yes, should you wait-only you can decide. It sounds like you are going ahead with your surgery and my opinion is that it may be good. The reason I say this is it sounds like you are in good performance standing now and most large companies are going to try to work with you. Better now than what if you start to decline and so does your performance over that time because you don't feel well! That is more of a grey area where your job could be more at risk. Fmla is a legal protection, but that doesn't prevent a company from offering you other paid or unpaid time off to resolve problems. Since we don't know all the particulars, I am just offering another viewpoint. I would talk to the director explain and ask for support.

    Even so as long as your health ins is active, the question to ask is regardless of FMLA do you have other benefits active? Do you have any STD/LTD benefits? Do they still cover you?

    It didn't sound like you are uncomfortable with your surgeon, I got you are worried about job and insurance!

    Good luck.

    Last edited by PNo; 10-30-2009 at 02:21 AM.

     
    Old 11-10-2009, 09:13 AM   #8
    happynessa
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    Re: insurance, fmla and a compressed cord

    I appreciate all the feedback I received on this post. I took time to research it further and discuss it with my surgeon and we decided to go ahead with the surgery. My case was a little different because not only did I have the herniation but I had subluxation at that same level and the two issues combined made for a delicate situation. So here I am 6 days post op and am so pleased to have it behind me. It has been so much more difficult and painful than I was expecting but I'm still here and still moving and I guess that's the point. Can't wait to get back to normal! Thanks again everyone!

     
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