YOU CAN REVERSE A HEALTH INSURANCE REFUSAL TO COVER A MEDICAL TREATMENT
ASK THE LAWYER : ALLAN J. GOLD
"You know Mr Stein, maybe you should just accept it... enjoy what is left of your life and not do anything" Actual quote Dr Viegant of the Régie de L'assurance-maladie
Think of it, you're suffering from a LIFE THREATENING illness and the treating
doctors have prescribed a particular procedure/treatment, but the time factor
is CRITICAL. Then the hospital/health providers in the jurisdiction of the Health
Insurance Organization can't perform such procedure/treatment on time. Would
the Health Insurance Organization cover this procedure/treatment if same was
readily available in another jurisdiction? Now consider the situation where
the treating doctors have prescribed a particular procedure/treatment, which
they believe will have a very important benefit to the patient, but same is
not performed by the hospital/health providers in the jurisdiction of the Health
Insurance Organization cover this procedure/treatment, if it was readily available
in other jurisdiction?
December, 1995: Stein was 41 years old in 1995 when he was diagnosed with colon
"...As surgical intraoperative placement of the hepatic infusaid pump is not performed in Quebec or Canada. I am willing to cooperate with the American doctors following the surgery on giving chemotherapy to this patient.
In view of the seriousness of the disease and the young age of the patient who is father of 3 children, the procedure has to be done as possible. Otherwise the prognosis is guarded.
April 12, 1996: The Régie wrote to doctors refused the request as follows:
"...I regret to inform you that the Régie de l'assurance-maladie du Québec is unable to grant Barry Stein authorization to be hospitalized outside Canada to receive the medical services recommended by his doctors".
April 16th, 1996: Stein reacted with shock and disbelief. He decided instead to follow the recommendations of his treating doctors and went to New York for the first operation, when Dr. Daly performed the liver resection (followed by traditional chemotherapy in Montreal).
January 1997: Stein then went to New York for the second operation, when Daly performed cryosurgery and installed the infusaid pump.
Subsequent to the subject procedures/treatments: Stein applied for reimbursement from/by the Régie, but the Régie refused his application therefore. Stein then appealed this decision to the TRIBUNAL ADMINISTRATIF DU QUEBEC (T.A.Q.), and this refusal was upheld. Stein then instituted proceedings (Motion In Evocation) before the Superior Court for the District of Montreal.
N.B. Stein was free of any recurrence of the liver lesions; and he and his treating physicians credited this state of good health to the treatments received from Daly in New York.
REFUSAL BY THE REGIE/UPHELD BY THE T.A.Q.:
Here's how the Honourable Madam Justice Carol Cohen J.C.S. saw the issues.
Ruling on the first operation:
"...This flies in the face of all logic. Stein and his doctors requested treatment in New York in April precisely because the surgery was not being performed in a timely fashion in Montreal and because it was more than 12 weeks since the liver lesions had been discovered. To maintain that it was reasonable to make Stein continue to wait for surgery in Montreal when the danger to his well-being increased daily is irrational, unreasonable and contrary to the purpose of the Health Insurance Act, which is designed to make necessary medical treatment available to all Quebecers..."
Ruling on the second operation:
"...Stein needed surgery on his liver in a timely fashion. Between January
and April 1996, he could not get that surgery in Montreal. The subsequent treatments,
which are not available here, saved or at least prolonged Stein's life. These
facts are uncontradicted. To refuse coverage in these circumstances is patently
unreasonable and the Court therefore intervenes to annul the T.A.Q.'s decisions..."
If a patient's life is in peril or his/her health is being undermined and/or is at risk, interpretation must be made for the purpose of WELLNESS, and reasonably, not only as per the letter of the law and indeed with common sense as well. Administration and rules do not serve death, but rather give way to wellness.
It is true that the Health insurance organizations must have a system and criteria and allocate resources for the common benefit, but health and wellness are the purpose of it all and if they are not acting towards this end, then they are rogue organization acting contratry to the laws, regulations, rules, and must be curtailed.
It is documented that Dr. Viegeant of the Régie had the unmitigated gall and BAD SENSE to say to Stein to forget further surgery and live his remaining days in peace, and also as follows: "You know, Mr. Stein, maybe you should just accept it. Maybe you should just enjoy your life and not do anything."
To this I say NO! NO! NO! Health insurance is designed to make necessary medical procedures/treatment available to all of its beneficiaries. This is an instance where Health insurance has gone mad. It has happened before, and it will happen again. This time, the good guy won. The lesson learned here is that if the treating doctors prescribe a particular procedure/treatment and Health insurance overrules them and refuses, then VIGOROUSLY FIGHT ON until the Health insurance will be told to be REASONABLE. LIFE IS PRECIOUS AND INDEED, IT IS WORTH FIGHTING FOR!!
CAUTION/DISCLAIMER: The foregoing article is only for informational purposes and is not meant as legal advice. Seek out legal counsel for your particular needs.
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