Denial Upheld
To: Greenmountain Health Care
Division of Denials
Dear Sir or Madam:
I am writing in response to your denial of coverage for my patient's extensive orthopedic and rehabilitative care. I am, as requested providing more detail. However, I fail to understand why, since the accident occurred last month, you are coding this as a "pre-existing condition.".
Joseph Sweatjock, MD Orthopedic Surgeon
My patient, Buddy Light, is a bricklayer by trade. On the day of the accident, he was working alone on the roof of a new six-story building. When he completed his work, he found he had some bricks left over which, when weighed later, were found to weigh 240 lbs. (At your request, we have sent the barrel and bricks to your offices by UPS.) Rather than carry the bricks down by hand, he decided to lower them in a barrel by using a pulley which was attached to the side of the building at the sixth floor. Securing the rope at ground level, he went up to the roof, swung the barrel out and loaded the bricks into it. Then he went down and untied the rope, holding it tightly to insure a slow descent of the 240 lbs of bricks. You will note on the hospital admission form that his weight was 135 lbs. (At your request, we have submitted evidence from an outside contractor that our scale is accurate to within 1/16 lb.)
Due to his surprise at being jerked off the ground so suddenly, he lost his presence of mind and forgot to let go of the rope. Needless to say, he proceeded at a rapid rate up the side of the building. In the vicinity of the third floor, he met the barrel which was now proceeding downward at an equally impressive speed. This explains the fractured skull, minor abrasions and the broken collarbone, as listed in the admission form and confirmed on the radiology report (at your request originals of all 385 x-rays are enclosed.)
Slowed only slightly,he continued his rapid ascent, not stopping until the fingers of his right hand were two knuckles deep into the pulley (see notes of abrasions on admission physical). Fortunately, by this time he had regained his presence of mind and was able to hold tightly to the rope, in spite of the excruciating pain he was now experiencing. At approximately the same time, however, the barrel of bricks hit the ground, and the bottom fell out of the barrel. Now devoid of the weight of the bricks, the barrel weighed approximately 50 lbs.(Again, please refer to the patient's weight as listed in the admission document.) As one might predict, using the principles of Newtonian physics, he began a rapid descent down the side of the building. (At your request, we have faxed you the entire text of Principia Mathematica by Sir Issac Newton.) In the vicinity of the third floor, he met the barrel coming up. This accounts for the two fractured ankles, broken tooth and severe lacerations of his legs and lower body. (Again refer to the 385 original x-rays that YOU requested we send you.)
At this point, my patient's luck began to change slightly. The encounter with the barrel apparently slowed him enough to lessen his injuries when he fell into the pile of bricks. Fortunately only three vertebrae were cracked. I regret to report that, as he lay there on the pile of bricks, in pain, unable to move and watching the empty barrel six stories above him, he again lost his composure and presence of mind and let go of the rope. (At your request, we have sent the rope by Overnight Express--note: the noose was added later.)
Please reconsider your denial of payment for these services. As you can see, the injury occurred three years after he signed up with your HMO. Please explain how this constitutes a "pre-existing condition."
First Level Reviewer: They sent everything we requested; I didn't think we'd get the bricks. I'm going to lose big in the office pool on that one. What are we going to do with the bricks? We already have a stone wall.
Second Level Reviewer: Have the patient come fetch them tomorrow after we discharge him.
First Level Reviewer: This case could cost us a lot of money. Probably our Christmas bonuses for the next two years!
Second Level Reviewer: Not to worry; We still have two excellent reasons to deny care. Clearly the underlying cause of the accident was stupidity. We don't cover mental illness or other mental defect. Secondly, the stupidity must have been a pre-existing condition--he signed on with us three years ago! hi odd ball, i loved your joke, blue Have you ever heard of the "Bricklayers Song"? I imagine that you have. |
