Insurance for PBT Battle

Here is my story and battle to be treated by proton beam therapy:
I have a high deductible ($5000) $2 million lifetime cap for major medical events with Assurant Health.   I am a small business owner and too young for Medicare (53 at the time) so I had to be thrifty with medical coverage and found this company to have reasonable rates.

But I had a very difficult time getting coverage with this quirky policy. Early on when I had decided my course of treatment I applied at Florida Proton Center since it was very convenient for me to travel there (1 hour away).  FPC informed I was only approved for $25,000 towards the $160,000 costs of proton treatment and I would have to come up with the balance.  They indicated PBT treatments were considered outpatient and I had a $25,000 cap on my outpatient plan.  I was quite frankly shocked and devastated with this information. I contacted my agent and they indicated it must be in the procedure codes and that the $2 million cap applied, but to make the this story short I was stuck with only a $25,000 outpatient policy. 

I appealed to FPC to give me an out of pocket cash price for the PBT treatment but they wouldn't budge on the $160,000 price (I presented various sources of information about the $36,000 cash fees we hear about, but they said this was urban legend). So I gave up on them.

Faced with a dim outlook for any treatment and not many resources I contacted Loma Linda Medical University.   They got an approval from Assurant to cover proton therapy for my prostate cancer.   It was a challenge to be away my from home and my wife had to run the business without me.    But we made it happen and that part of the story is history.

Unfortunately after returning home from LLUMC Assurant decided again to cap my treatment costs at $25,000. So I received a $120,000 medical bill in the mail from Loma Linda.  This sucks!   We called LLUMC and they agreed to back off until we resolved this issue with Assurant.

We appealed to our Insurance Commissioner in Georgia but they were not confident in the outcome.  Faced with this large medical bill we pursued the case and finally won.  Assurant made an executive decision to pay the treatment costs. Halleluiah!

Moral of the story:   Check your policy and make sure you know clearly what procedures are covered and how much they will cover for radiation, chemo, and other outpatient cancer processes.   I found out later for $30 more a month that I could have had unlimited coverage in outpatient procedures.   At this point I am stuck with this policy and won’t be able to increase or move to another company since I have this preexisting condition and not considered cured until I reach .5 PSA nadir for 5 years.   This will probably not happen so I am stuck with a $25,000 cap on any outpatient procedure until I reach 65 when Medicare kicks in, and that’s a way off.  We did drop my wife from the policy and moved her to Blue Cross Blue Shield Smart Sense.  It has a $5 million cap on outpatient for all cancer processes.  Trust me we studied this policy closely.

I hope no one else gets in this position.   It’s dreadful enough to be diagnosed with PC and then deal with the process of getting coverage.

Take Care and good luck to all!

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