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My sister’s government-funded insurance declined to pay for life-saving surgery | Opinion

By Dave Rosen

For three years, my sister in Saddle Brook has been battling colon cancer. The state-issued insurance supplied to New Jersey employees only added to that battle. Here’s why.

Michelle, who has been stoic since her original Stage 3 diagnosis, learned this spring after being in remission for several months that her doctors saw troubling markers, which again showed signs of disease. Her physicians at Memorial Sloan Kettering strongly recommended surgery to remove any visible cancer, followed by a chemotherapy “bath” in the abdomen before the incision is closed. For decades, this has been a successful and standard treatment for abdominal cancers in the USA and around the world.

However, one week before the surgery, after all the pre-operative tests and mental preparation, her government-funded health insurance provider, through her husband’s employer, the New Jersey Veterans Home at Paramus, denied coverage for the surgery. The company determined that the procedure was “not medically necessary.” Her stunned doctors went through the appropriate rounds of appeals to no avail.

Michelle was beyond upset. “Some of the world’s top doctors, who’ve dedicated their lives to studying and treating my specific cancer were overruled by an insurance company and state bureaucrats on whether this surgery was medically necessary,” she told me.

Of course, the surgery would not be scheduled without payment up-front, so with no time to waste, Michelle and her family were forced to borrow the incredibly large sum. This was life-altering debt for a working-class family. It should also be noted, Michelle’s original diagnosis came when she was 49 years old. At the time, a year too young for insurance plans to cover a colonoscopy, the test which could have detected her cancer at an earlier stage.

Dave Rosen and his sister Michelle Rosen-Levy

During this process, we also learned about “self-funded” insurance policies. About 75.5 million employees in the United States, or 63% of all workers, were insured under these kinds of plans in 2015, but few people realized this. These plans are something the public should know about and understand. With these types of policies, your employer is the ultimate decision-maker on whether a health condition can be covered.

New Jersey contracts with Horizon Blue Cross/ Blue Shield of New Jersey to administer the policy, but the full cost of the payouts comes from the employer. That means that the denial letter comes from the insurance company but the employer is in charge, says Laurie Todd, who’s also known as The Insurance Warrior. The employer can intervene and approve coverage for procedures like this, but they have no incentive to do so. It costs too much.

In Michelle’s case, the New Jersey Division of Pensions and Benefits has the power to decide what care they will pay for.

So who told this state agency to deny Michelle’s surgery? We decided to research the doctors employed by Horizon Blue Cross/Blue Shield, and at least in Michelle’s case, the doctors had limited or no expertise in the treatments her Memorial Sloan Kettering and Cancer Institute of New Jersey doctors were recommending. How can this be an acceptable way of doing business?

Now I’ll admit, I’m writing this for selfish reasons — to vent, to yell from the rooftops. You see, Michelle is my big sister. My only sibling. Witnessing what this insurance nightmare is doing to her, her family and our aging parents make me feel completely powerless… and furious. It is also devastating to know our situation is not unique.

I thought, perhaps as you make your way to the polls this November, you should know how current state insurance plans and the leaders that implement them are saddling New Jersey families with generational debt. Shame on them all.

The good news here is that Michelle’s surgery has been a success, so far. But there are follow-up procedures ahead and a rough road to managing this significant financial debt.

“All we can do now is worry about how we’ll ever be able to pay for it all,” Michelle tells me. It’s just another “perk” of living and working in New Jersey.

Dave Rosen lives in Ringwood with his wife and young children. He and his wife run an audio mastering studio et un pro audio gear company. His sister, Michelle Rosen-Levy, and her family have set up a GoFundMe to help pay for the surgery.

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