Dive Insurance...What is really covered?

[Christi]

Frankly (and I realize I'll take crap for saying this) the whole discussion has made me rethink ... and the safety of diving Cozumel...

This has nothing to do with the safety of diving Cozumel. The only way to insure not getting bent at all is to stay out of the water. As proven here, you CAN get bent after only one dive and you can get bent doing everything "right." There have been cases of people getting bent in 20 feet of water...Decompression theory is JUST THAT...THEORY. It is not an exact science.

 

[gerardnealon]

Trust me, this Dr.'s fees are definitely reasonable and customary. They are about $100 an hour less than the other chamber on teh island and about $300 an hour less than other Caribbean chambers. He is more concerned with the patient than the $$.

if that is the case then I would definitely fight them on that. Hope everything works out for your friend.

 

[MikeFerrara]

This is not the first incident of this, which is why I am speaking up about it. They are trying to dictate what treatment is enough for each and every patient and it's not right. If the patient has a policy for $45,000 and $15,000 of treatment is needed (hospital fees as well) as determined by the Dr. (who IS NOT overtreating him by the way...if anything he was undertreated), then they should cover him.

I'm sure if one of them was laying there in need of treatment they would get it.

It may or may not be right but all insurance companies do it. People are denied treatment and released from hospitals before the doctor wants them to go all the time because the insurance companies put caps on stays for specific treatments.

Insurance companies always reserve the right to make the call in their policies. Just because a policy says they cover up to X number of treatments it doesn't mean that they will cover that many in every case. It means that they will NEVER cover more than X. They are setting maximum limits, not minimum limits.

 

[MikeFerrara]

This has nothing to do with the safety of diving Cozumel. The only waty to insure not getting bent at all is to stay out of the water. As proven here, you CAN get bent after only one dive and you can get bent doing everything right. There have been cases of people getting bent in 20 feet of water...Decompression theory is JUST THAT...THEORY. It is not an exact science.

Maybe you can get bent when you think you're doing everything right but lets face it...if you get bent you did something wrong.

Do you have a reference that documents some one getting bent in 20 ft of water?

but as said, another treatment would have been beneficial.

How do you know that?

 

[gerardnealon]

This has nothing to do with the safety of diving Cozumel. The only waty to insure not getting bent at all is to stay out of the water. As proven here, you CAN get bent after only one dive and you can get bent doing everything right. There have been cases of people getting bent in 20 feet of water...Decompression theory is JUST THAT...THEORY. It is not an exact science.

The Dr. was willing to treat him again, but knowing that DAN wasn't going to cover it, he decided to hold off and observe him closely to make sure he didn't digress with his symptoms again and confined him to bedrest. He is still making improvement day t day, but as said, another treatment would have been beneficial.

Did you say he dove the same day he flew in? Maybe that had something to do with it. I know you are not supposed to fly after a dive, but not sure if its true the other way around.

 

[HammerNoMore]

Nope James, I read the letter. I've been very close to the situation from the start. It clearly stated that they would only cover four treatments at X rate because 4 treatments is customary in Cozumel (how can they make this assumption for all cases of DCS). All protocol was followed, DAN was contacted to authorize treatment up front. They feel that 4 treatments is sufficient.

Again, I think this is always a mistake, though I could see why the doctor would do so to make sure he will be paid, it is in his best interest. Emergency services never require pre-authorization, and asking before hand is looking for a no answer. The policy (I'm assuming your friend is from the US here, if not it changes things significantly) clearly states that authorization is required for more than 7 treatments. If your friend pre-authorized and was told only 4 were allowed and then proceeded to do 5, he may very well be stuck on the 5th one. Had he just been treated, I feel certain that the insurance company either would pay or would be easily compelled to pay for the 5th.

Either way I would recommend your friend start out by investigating the dispute path with this insurance. On the one occation I disagreed with an insurance companies decision, I skipped the arbitration phase and just contacted my state's insurance commissioner, copying the company on all corisponance. That tends to clear things up rather quickly. If your friend is from Texas, he can file a complaint online at https://wwwapps.tdi.state.tx.us/inter/perlroot/consumer/complform/complform.html .


All of this is of course based on the information we have here. Again, it's always easy to assume the insurance company is wrong (and I'm speaking of the dozens who jumped on the bash the insurance company bandwagon, not of you personally)...despite the works of John Grisham, they know their legal position quite well and rarely deny coverage they are legally required to pay. As a busiess it would be irresponsible of them to pay one cent more than requried.

This is not the first incident of this, which is why I am speaking up about it. They are trying to dictate what treatment is enough for each and every patient and it's not right. If the patient has a policy for $45,000 and $15,000 of treatment is needed (hospital fees as well) as determined by the Dr. (who IS NOT overtreating him by the way...if anything he was undertreated), then they should cover him.

There is nothing specific to the DAN sponsored insuance about this. All insurance companies dictate standards and costs of care. The doctors agree to these standards/costs when they become affiliated with the insurance company. Without this arangement there would be no check to the amount a medical provider would charge for services and both health insurance and treatment would be financially out of reach for all but the upper incomes.

Those of you who think you will be treated any differently by any of the other companies are just kidding yourselves.

James

 

[Scuba_Steve]

Maybe you can get bent when you think you're doing everything right but lets face it...if you get bent you did something wrong.

I'm quoting Mike here, as I tend to agree for the most part in what he's saying.

I will agree that it is possible to take a pretty much undeserved hit, but I think the reality is, most people that get bent, upon further study, could give you at least a very good indicator as to why/how it happened.

Christi:

Could you possibly further inform us of the following:

You said 70ft for 42 TRT (With the 3 min S/Stop). First dive of the day.

What was his ascent rate? Computer profile?? Does anyone remember when they left the bottom? (IE Leave bottom @ 38min, arrive at stop at 39min, 3 min S/S, Hop on the boat) uhmmm, not a good profile, but it adhere's to the standard doesn't it. Food for thought.

I'm just looking at the details. I also assume he's diving air.

Diving air, ascent speeds that are too fast........to me these are not stressed near enough as the culprits they really are. 30pfm is a good ascent speed, They also feel dreadfully slow and are quickly turned up a notch.

I will admit, my pet peeve are fast ascent rates.....most people I see are ascending way to fast (For my comfort).

Thanks

Steve

 

[Christi]

Maybe you can get bent when you think you're doing everything right but lets face it...if you get bent you did something wrong.

Do you have a reference that documents some one getting bent in 20 ft of water?

How do you know that?

I had previously written a post documenting his entire incident. The most likely culprit was dehydration.

When I say you can get bent doing everything right, I am speaking in very general terms. However, the fact remans that there are cases of "undeserved" hits. I don't think his was undeserved, because he was clearly dehydrated (flew in that day, drank several sodas and coffee, one glass of water all day).

I don't have an internet reference for the 20 foot hit, but it happened to a friend of mine on a 20 foot shore dive in Bonaire. It was also her first dive of the trip. She could very well have had other mitigating factors causing her hit, but as far as her profile and dive procedures went, she did everything "right." My point is that too many people are fooled by the fact that they will be ok on a shallow dive and/or as long as they follow their computer or the tables, simply not true. There is SOOO much more to it than that. Hydration, proper rest, exposure protection, general health, topside behavioractivities before and after the dive, etc. Stuff everyone learns in basic open water training, but many soon forget or don't take seriously.

How do I know another treatent would have been beneficial?

Besides the Dr.'s opinion, as you may or may not know, that as long as a patient is showing marked improvements with the treatments, further treatments are beneficial. Once they reach a plateau regarding their improvement over a couple of treatments, then additional treatments are not beneficial, although not harmful either. He was making significant improvements with each and every treatment. I took him to the chamber everyday and was there dueing every exam before and after treatments. I was also with him and his wife in between treatments.

Gordon, I should have said that the Dr. called to verify coverage...no to authorize treatment. Bad word choice on my part.

Godon and Mike, I understand what you are saying about insurance companies in general, but it certainly doesn't make it right. What is the point in having maximum limits and leading people to believe that they are covered for a certain amount if they have to fight it everytime? I also realize that this is the underwriter we're dealing with here, not DAN itself.

Obviosuly, this has me upset because this is a good friedn of mine and he was in BAD shape. It was sad and scary and it infuriates me that he is having to fight to get a very reasonable treatment protocol covered.

Rant is off again...thanks for all the opinions and feedback.

 

[Natasha]

Thanks for the info Christi.

I'm happy to hear your friend is doing better.

 

[Christi]

I'm quoting Mike here, as I tend to agree for the most part in what he's saying.

I will agree that it is possible to take a pretty much undeserved hit, but I think the reality is, most people that get bent, upon further study, could give you at least a very good indicator as to why/how it happened.

Christi:

Could you possibly further inform us of the following:

You said 70ft for 42 TRT (With the 3 min S/Stop). First dive of the day.

What was his ascent rate? Computer profile?? Does anyone remember when they left the bottom? (IE Leave bottom @ 38min, arrive at stop at 39min, 3 min S/S, Hop on the boat) uhmmm, not a good profile, but it adhere's to the standard doesn't it. Food for thought.

I'm just looking at the details. I also assume he's diving air.

Diving air, ascent speeds that are too fast........to me these are not stressed near enough as the culprits they really are. 30pfm is a good ascent speed, They also feel dreadfully slow and are quickly turned up a notch.

I will admit, my pet peeve are fast ascent rates.....most people I see are ascending way to fast (For my comfort).

Thanks

Steve

Yes, I agree for the most part too Steve, and explained myself a little better in my last post.

I have personally logged many dives with my friend, and although I wasn't on this dive with him, I have always observed hi to be nothing short of responsible and safe when it comes to his dive procedures and ascent proceures. He did indicate that they did not do a multi-level profile, which I would have done on this dive. I also looked at his computer and there was no indication of a fast ascent. His ascent started at 35 minutes, which would have indicated a 4 minute ascent from 70 to 20 feet. Then the 3 minute safety stop between 15 and 20 feet. I always follow the deep stop rule (1/2 max depth), but he wasn't diving with me...I wasn't there. Still, this was a "safe" ascent.