GMA – Biased Insurance Doctors / Multiple Sclerosis – Video Transcript
[GRAPHIC: GMA Gets Answers]
CHRIS: We bring you the latest in our GMA Gets Answers series. This is a story of a man with Multiple sclerosis, a chronic and disabling disease that attacks the central nervous system. Now, after being diagnosed with MS by no fewer than 11 doctors, remember that, he became worried that the insurance money he was expecting might never come. Here’s why.
CHRIS: Charles Tucker has always lived his life to the fullest.
CHRIS: The 48-year-old accountant lives in Titusville, Florida, and supports his wife, two daughters and baby grandson.
[GRAPHIC: Family Christmas]
CHRIS: About two years ago, he started developing frightening symptoms.
CHARLES TUCKER: I started having numbness in the hands and feet, severe, severe headaches.
CHRIS: He was so tired he was falling asleep at work. Unfortunately what he thought was stress and fatigue was something much worse. His neurologist is Dr. Daniel Nieves Quinones.
DR. DANIEL NIEVES QUINONES: He is suffering from Multiple sclerosis, which has basically disabled him from performing his occupation.
CHRIS: Too sick to keep working, reluctantly Charles left his accounting job.
CHARLES TUCKER: It was a very emotional and very difficult thing to do to leave my job and wonder, you know, how I was going to provide for my family.
CHRIS: Luckily, he had been paying for long-term disability insurance with the Standard Insurance Company.
[GRAPHIC: The Standard]
CHRIS: So last June, Charles filed a claim with Standard. He didn’t receive a denial, but for months he couldn’t get an answer. All he got were notices they needed more time and requests for more information. Charles was worried. So he obtained his records from Standard.
[GRAPHIC: Medical report]
CHRIS: Inside his file he discovered a surprising medical report from a doctor who works for Standard. That doctor never met Charles. It was the expert opinion of 11 doctors that Charles has MS. But the insurance company doctor didn’t agree.
[GRAPHIC: Medical report]
CHRIS: In this official report he said, “The diagnosis of Multiple Sclerosis is not supported and the patient could return to a sedentary work activity.”
CHARLES TUCKER: I was just devastated. I mean it took me almost two years to really accept the fact that I did have this disease. I had all these doctors telling me I did. And then this guy who has never seen me would say something like that.
CHRIS: Charles’ doctor said the insurance company doctor never even contacted him about Charles.
DR. DANIEL NIEVES QUINONES: If you haven’t seen a patient you can’t really say things that he has been saying.
CHRIS: And Standard Insurance Company isn’t alone. Most insurance companies hire their own doctors to review patients’ claims without any in-person examination. John Morrison just stepped down from his job as Montana insurance commissioner. He says doctors who work for insurance companies risk being in their pocket.
JOHN MORRISON: There’s no question that in certain cases disability income carriers and health carriers use hired gun physician opinions in order to deny claims.
CHRIS: Morrison says what’s worse, in 39 states insurers can add legal language to their policies called discretionary clauses.
CHRIS: Which enable them to uphold the claim denials in court based on evidence such as that provided by their in-house doctors.
[GRAPHIC: The Standard]
JOHN MORRISON: I think it’s an inherently unfair process.
CHRIS: We went to Susan Pisano from the health insurance lobby group for answers.
Critics call these in-house doctors hired guns. How can you expect to be seen as fair if you’re paying the person who makes the determination?
SUSAN PISANO: $10 billion are paid out in claims every year. 500,000 people are receiving disability claims annually.
CHRIS: They don’t even see patients, they just look at these files?
SUSAN PISANO: You know, I happen to know a lot of physicians who are employed by disability carriers. The typical profile is a very smart, very compassionate physician who understands the health care system.
CHRIS: I can’t even get antibiotics over the phone with my doctor.
SUSAN PISANO: So…
CHRIS: You know what I’m saying? But you can find out that you don’t have MS or Leukemia from somebody who’s never seen you.
SUSAN PISANO: Well, my understanding of the way this works is that the reviewer is looking at whether the medical record supports those claims.
CHRIS: Charles contacted GMA and we began getting answers.
CHRIS: Standard wouldn’t talk to us on camera but they did give us this statement saying they thought Charles’ claim was handled in a thorough, responsive, ethical and fair manner.
Charles waited for Standard to approve his claim for five months, living in limbo. But just a day after we called, Standard told us they were now approving his claim. They said an independent medical review confirmed Charles does have MS after all.
Standard is now paying Charles about 40 percent of his old salary. So now he can support his family. But he still worries about the others in his shoes.
[GRAPHIC: Tucker family]
CHARLES TUCKER: It’s just been absolutely terrible. And I don’t think people ought to have to go through this.
CHRIS: And to be clear, the company Standard says they paid Charles when he became eligible. He and his lawyer are grateful to Good Morning America but that’s all beside the point. The main point here is Charles is getting paid. He’s getting the checks from Standard now. His family is okay.
And it also makes the point that this is all about you out there. You hear this story, you get in contact with us, you let us know what’s going on. We’ll make some calls. That’s the way GMA Answers works. So thanks, go to the website, ABCNews.com. You’ll learn more about this and you can tell us what’s going on in your life.