Veteran with heart condition says insurance company denied coverage 4 times
A southern Indiana veteran was prescribed a Zoll Life Vest, an external defibrillator, to protect his life while battling a heart condition. But his health insurance company has denied coverage for the device.
SALEM, Ind. (WDRB) – A southern Indiana veteran was prescribed a Zoll Life Vest, an external defibrillator, to protect his life while battling a heart condition. But his health insurance company has denied coverage for the device.
The Nunley family was hit with tragedy in November 2016 when 31-year-old Matthew Nunley was diagnosed with congestive heart failure as a result of a the flu. Doctors told Nunley it was a one-in-10,000 chance a virus would attack his heart like that. His heart was functioning in the 10-15 percent range when he was diagnosed.
Doctors prescribed Nunley five medications and a Zoll Life Vest for three months. The vest was designed to monitor his heart rate and shock his heart back into rhythm if anything went wrong. By March, his heart function was up to 30-35 percent.
“It was really kind of a surprise for us when the medicine worked,” Matthew Nunley said. “Because they said there was only a 25 percent chance of the medicine working. I was fully expecting having to do open heart surgery. So that’s a blessing.”
While his heart was slowly growing stronger, his family was losing a battle with the insurance company. Wearing the vest for just over three months will cost between $11,000 and $14,000. The total will depend on if Anthem prorates the cost.
“We do what we’re supposed to do,” said Shelby Nunley, Matthew’s wife. “We pay the bills. We do everything we’re asked to do, and then we’re stuck with tragedy. And instead of Anthem being there to help us to make this tragedy easier, instead, they make the burden even greater.”
Shelby said they appealed Anthem Blue Cross a total of four times, which is the maximum amount of appeals allowed.
During the third appeal, the Nunleys and a Zoll representative were included on a phone conference call with Anthem representatives. Shelby said they provided the facts of Matthew's medical condition and explained the need for the cost to be covered. But she said they felt like Anthem could not understand their frustration because of the qualification of the doctor representing Anthem's board of directors.
“He shared with us that he was a gynecologist making the decision on a 31-year-old man’s heart," Shelby Nunley said. "It was very frustrating to both of us. I even explained to them we’re not making a decision on an early hysterectomy. We’re making a decision on a cardiovascular case for a male.”
After the third denial, the case was sent for an external appeal, which was also denied. The letter cited the device was “experimental” and not “medically necessary.” According to the letter, Anthem had requested that Matthew Nunley had first undergone three months of medication before considering using a Life Vest.
“We struggle to understand how the vest could not be medically necessary if we weren’t allowed to leave the hospital without it," Shelby Nunley said. "Because we had to have some way to give his heart an immediate shock, if needed. And that vest was the only way.”
“They’re the only ones that consider it an experimental device," Matthew Nunley added. "Everyone else, including myself, understands it’s a life saving device.”
The vest never had to shock his heart back into rhythm. But Matthew Nunley said it did beep several times, warning him something could soon go wrong.
“When it would give me a warning that I was getting close to my heart being off beat, at that point I could know, 'OK, I need to stop what I’m doing. Whatever it is, whatever is stressing me out, I need to calm down,'" he said. "Even if it never went off, it never went off because it has a warning system. Without that, I don’t think I’d be sitting here today.”
The family is considering getting a lawyer, but they worry it could be another losing battle. They hoped they would be the first case for Anthem to change its policy regarding the Life Vest. Matthew Nunley believes it is the only company that does not provide coverage for the Zoll device.
The couple expressed gratitude for the Zoll representatives that helped them with each appeal. And they encourage anyone fighting any sort of insurance company to be persistent and thorough.
The small family is growing, as Shelby is expecting their second child. The Nunleys currently pay about $1,000 each month for the hospital bills. Adding the Life Vest and soon bills from giving birth, the family feels a lot of stress.
“We’re always reminding each other, 'Don’t worry, we’ll get through it. It’s just one more hurdle,'" Shelby Nunley said. "But we’re getting tired of the hurdles.”
Shelby’s mother started a GoFundMe account after the first appeal was denied. It is still active, if anyone would like to donate toward the family’s medical expenses.
Matthew Nunley is a veteran, and the family considered utilizing VA services. But they explained when they did their research that the best cardiologists were not with the local VA.
WDRB News has reached out multiple times since December 2016 for a comment from Anthem. The company has not yet responded.
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