Vicky's Healthnet Second Appeal Letter
ATTN: Member Services Appeals and Grievances department
P.O. Box 10348
Van Nuys, CA 91410-0348
I have received your written letter dated December 1, 2005 denying my request for surgery in India but approving it with Dr. Amstutz of JRI. I would like to appeal this due to the fact that, as noted in the timeline below, your letter to me did not arrive until after my surgery date of December 1, 2005, which I had previously revealed to you. Had I received your letter in a timely manner, I would have been able to schedule my surgery with Dr. Amstutz and cancelled my surgery with Dr. Bose. I believe that, legally, Healthnet should have informed me by phone of the decision and not waited to send the letter on the date that Healthnet was aware that I was already scheduled for surgery with Dr. Bose in India
I would like to note the following dates:
I spoke to Jammi H. at Healthnet, to find out what I needed to do since Bay Valley had denied my initial consultation with Dr. Amstutz, which to me meant they were denying the entire procedure as well. That person informed me that I needed a formal refusal from Bay Valley Medical group to send to Healthnet for my appeal.
On 9/19 3:00 pm
I left a voicemail message for Shelley at Bay Valley to please expedite the denial letter. Shelley called me back and left a voice message stating that the denial letter was to be mailed out the next day, 9/20, via certified mail.
Received denial letter from Bay Valley, and put together a detailed package for my appeal that went out to Healthnet on October 5, 2005. One month later, I received a call from Healthnet stating that the denial letter was only for a consultation and that I needed an actual denial for the resurfacing surgery before they could proceed. I told the person to hang on to the package and that I would fax her the denial letter as soon as I received it. I immediately called my general practitioner who in turn submitted a request for surgery in India. Bay Valley then faxed over a denial letter to my GP and I in turn faxed that to Healthnet on November 2. I phoned Healthnet to make sure it was received on November 3 asking them to please expedite this appeal as my time was running out. I clearly stated in my original letter dated October 5, 2005 that I was in unrelenting pain and that I needed a quick decision. I also stated that I had a surgery date scheduled with Dr. Bose in India on December 1, as my pain was unbearable, and it was affecting my ability to work.
Your letter of denial for surgery in India but approval for surgery with Dr. Amstutz was dated on December 1, 2005, the date I was already in surgery with Dr. Bose in India. I believe that legally you should have informed me of your intent to approve surgery before the date I was scheduled for surgery in India. I now appeal this denial and request re-imbursement of the original $350 for the consultation I had with Dr. Amstutz (which is now approved) as well as the $6,000 in medical fees that I incurred for my surgery in India. Here are the statements that were in my original letter dated October 5, 2005:
I understand your normal appeal process can take up to 30 days. But I would ask somewhat quicker consideration. I am in unrelenting pain, with diminishing mobility, and I think I’ve waited for longer than a reasonable person might. My condition is rapidly deteriorating. Since there are no doctors currently trained to use this device in the United States I have tentatively scheduled my surgery for December 1, 2005 with Dr. Vijay Bose in India”
Attached are the original letter dated October 5, 2005 and the letter from Dr. Bose for travel Visa.