(NewsSpace.com) – There’s no denying that the United States has a major healthcare problem. Tens of thousands of people die each year because they can’t afford to get the help they need. Sometimes, however, even when they do have insurance, the insurance company can deem procedures or treatment as “not medically necessary.” That’s what happened to one couple whose infant son needed emergent care and they received a whopper of a bill in the mail.
The Hospital Visit
Last year, Sara England noticed that her 3-month-old son, Amari Vaca, was struggling. Since he had undergone open-heart surgery just two months prior, she took him to Natividad Medical Center in California at the advice of his cardiologist, and things quickly went downhill. While in the hospital, the baby declined rapidly, necessitating a visit to a specialized hospital. Doctors even intubated Amari and manually provided him with oxygen until he was stable enough to go on a ventilator. Then, a bed opened up and they transported him, via air, to the University of California-San Francisco Medical Center.
Eventually, the baby was diagnosed with RSV and had to spend three weeks in the hospital before he was cleared to go home.
Air Transport Not Covered
A few months later, the bill came in the mail and it shocked England, particularly because her son was covered by insurance. However, one notable part of his treatment was declined as not medically necessary—the flight to UC-San Francisco Medical Center. That left England on the hook for $97,599. Cigna, the insurance company, refused to cover any part of the cost, stating that the patient could have been transported via ground ambulance. The hospital was nearly 100 miles away.
In the declination, Cigna said there was no documentation that noted ground transport “would impede timely and appropriate medical care,” and that there were no “great distances or other obstacles” that prevented the use of an ambulance.
No Given Standard
One of the major acts of federal legislation that is designed to prevent unnecessary costs, the No Surprises Act, has a loophole that insurers can take advantage of. It allows them to determine what is “medically necessary.” There is no standard and that term can be applied differently to each case.
This is a battle that England is still fighting. Cigna has denied her appeals twice and she’s now in the process of undergoing an external review. But despite providing his care and making the decision to call air transport, the original treatment center, Natividad Medical Center, declined to provide England with a letter on his behalf, citing facility policy. Cigna has since offered a representative to help her, but she continues to fight, stating “It’s just another stress. Another thing to get in the way of us being able to enjoy our family,” and she’s not alone.
Millions of Americans continue to fight the fight with hefty medical bills, a problem that has only seemingly grown worse over the years.
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