Couple beats cancer, but not the insurance company

A year ago, Gary Smith did not know whether he would live to see this Christmas holiday because of a devastating cancer diagnosis. Today, Gary is alive and well, but now his battle is with MVP Health Care, his insurance company which is refusing to pay for what he says was a life saving operation.

Last December, Smith, a civilian employee with the 174th Air National Guard, had been diagnosed with spindle cell sarcoma of the larynx, which his doctor told him was a rare and very aggressive form of cancer. At the time, Gary was faced with the possibility that half of his larynx would be removed to save his life. But he and his wife, Kelly learned of a type of operation call Trans oral laser micro surgery which would keep his larynx in tact yet still remove the growing tumor in his throat. He says his doctor in Syracuse recommended that he see a specialist, Dr. Bruce Haughey at Barnes Jewish Hospital in St. Louis. The couple asked MVP to approve an "out of network" specialist to handle the delicate operation, but MVP had recommended 5 other surgeons who were in the company's network of approved doctors.

Kelly says they received mixed signals from MVP. Though Dr. Haughey was "out of network" for MVP's health insurance coverage, he was approved to conduct a second opinion of Gary's worsening condition. On January 6th, Gary Smith visited with Dr. Haughey who determined that he was in urgent need of surgery. On January 10th, Smith underwent a successful operation to remove the tumor from his larynx. Smith told CNY Central's Jim Kenyon, they had little time to waste.

In March, the couple received word that MVP had denied their claim for coverage and owed $21,000 for the surgery. Two subsequent appeals through MVP failed as did a third appeal with the United State Office of Personnel Management. Though they may be on the hook for $21,000, Gary says he "won" because he's alive today and his surgery was a success.

A spokesperson for MVP Health Care said the law governing privacy "prohibits MVP from discussing specifics about members in their care and we take that obligation seriously and are honoring it here."

Kelly Smith says their situation points out the need for health insurance reform especially when it comes to "out of network" health care providers.

She's not alone. Last March, the New York State Department of Financial Services released the result of an investigation into thousands of similar complaints from patients who were denied coverage by insurance companies because they received care from out of network providers. In many of the cases, the patients were unaware that a doctor may not qualify. The DFS found an "overwhelming need for more transparency and better consumer protection so consumers stop getting surprise bills."

Financial Services Superintendent Benjamin Lawsky said, "Our report shows that all too often people who try their hardest to stay in network still get stuck with the most unwelcome surprise-- a big out of network bill. We need to reform our system now to protect middle class New Yorkers who can least afford these additional burdensome costs."

Governor Andrew Cuomo said, "The high cost of health insurance and health care are an enormous burden for most New Yorkers. Our investigation shows that too many people are being hit with medical bills that are too high when they thought their care was covered by insurance. We can not allow that to continue."