Insurance Ruling Leaves Cancer Patient In Limbo

November 06, 1990|By Peter Hermann | Peter Hermann,Staff writer

Judy Marsh thought she had a good chance to get rid of her cancer. She had endured weeks of tests and was to drive to North Carolina this week to have a bone marrow transplant.

If successful, the procedure could free the 49-year-old Pasadena woman of the deadly disease. She was told not to worry by officials at Duke University Medical Center in Durham -- she only had to wait for the insurance company to OK the procedure.

But last month, Marsh got the news that her insurance company, Blue Cross/Blue Shield, would not pay for the procedure. The company contends that medical insurance available to federal employees, and retirees like Marsh's husband, Rolland, does not cover "experimental" medical procedures.

Now Marsh is in a frantic battle. She must come up with $94,000 by the end of the week in order to be admitted to the hospital. And if she isn't admitted by the weekend, weeks of tests will have been for nothing.

Timing is everything, because she is not receiving bone marrow from a donor, but rather will be having her own marrow removed and filtered back into her body after high doses of chemotherapy are administered.

"I have to be in the right condition health-wise," Marsh said. "There is a 50-50 chance at survival. If I get an infection, I will die because I don't have any bone marrow. I know all this, but I don't have a choice."

Marsh, who has two grown sons and a granddaughter, found out she had breast cancer in June 1988. Chemotherapy didn't help, and the cancer spread to her lungs.

Marsh, who lives in the 7900 block of East Shore Drive, was told that an autologous bone marrow transplantation was her only hope for survival. But an insurance adjuster at Duke medical center told Marsh that Blue Cross of North Carolina sent a letter explaining that the company would not pay for the procedure, which could cost as much as $170,000.

That decision runs contrary to the company's patient insurance handbook, which states that Blue Cross covers such transplants up to $100,000, Marsh said.

Liz Wagner, an aide to Representative Tom McMillen, D-4th, who is trying to get Blue Cross/Blue Shield to pay for Marsh's procedure, said the woman was turned down because the type of health plan the couple has doesn't cover experimental procedures. The policy guidelines are set, she said, by the federal Office of Management Personnel.

But Wagner said the American Medical Association says the procedure is not experimental and deems the procedure a reliable way to treat certain types of cancer.

"You can see what I'm up against," Wagner said.

Robert Flohr, director of claims services for the Federal Blue Cross/Blue Shield Benefits Program in Washington, said that, to his knowledge, Marsh has not been turned down. He said the company is waiting for more information on the procedure from doctors in North Carolina.

He also said if Marsh is turned down, she can appeal to the Office of Personnel Management in Washington.

Marsh is not alone in her predicament. A woman from Riviera Beach, who is a federal employee, just settled out-of-court with Blue Cross after intervention by McMillen's office, clearing the way for an identical bone marrow transplant. She also had breast cancer.

The woman did not want to be interviewed or have her name used because she has not yet received money from the settlement. Her pastor, the Rev.

John Douglas of the Emmanuel Lutheran Church in Pasadena, said he is horrified by the actions of the insurance company.

"They are forcing people to sue for their own benefits," he said.

Douglas said the woman has just come home from the hospital and is doing fine. He said the insurance company settled only two weeks after the suit was filed.

In another case, Arnold resident Eva Simmons won a court fight to have Blue Cross pay for her bone marrow transplant after an emergency hearing before Circuit Judge Eugene M. Lerner last month .

In that case, Blue Cross officials also argued the procedure was experimental, and therefore not covered under the group health plan held by her husband, a state employee.

Marsh has not yet decided if she will sue the company. She said she wants to wait until McMillen's office gets back to her.

Meanwhile, friends and neighbors have pitched in to raise money for her hospital stay. Initially, it was going to be money only to make up the difference between the hospital cost and the $100,000 the insurance would pay. But now things have changed.

A Pasadena restaurant is having a dinner next weekend to raise money. A family friend is raffling off use of a condominium in Ocean City and other relatives have started fund-raising drives across the country.

Rolland Marsh, who processed medical claims for the Social Security Administration for 31 years before retiring just two weeks ago, says he will sell the couple's house if necessary. "She will have that operation," he said.

But time is against them. If it doesn't go off next week, it may never be possible.

"I'm determined to live," Marsh said. "I'm just not ready to go yet. I just love life. I have so much to live for. I want to take that chance with the operation. I'll be in isolation for six weeks.

"I'll have to stay in bed at home for six months. But there is a chance I can walk out of the hospital cancer-free. Blue Cross and Blue Shield is not even giving me the chance."

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