What Happened

Not long ago, I had a pretty decent smile. Then on November 23, 2010 I had a bike accident. My wheel slipped through two metal grates on the Lasalle Street Bridge in downtown Chicago. The bike stopped moving in a split second but my face kept flying forward and met the bridge hard. It must have looked a little something like this. It hurt. It hurt a lot. I managed to stumble off of the roadway. There was blood everywhere. Someone called an ambulance and I took a ride to Northwestern Hospital. Moving my tongue through my mouth, it was clear that things weren’t right. In fact, the contents of my mouth had moved around quite a bit. X rays were taken. I had some deep facial lacerations(graphic), three teeth and some jaw knocked out (graphic), and six more teeth jarred loose. Dental residents splinted my loose teeth with wire, my face was sewn up–rather excellently, I might add–and I was sent home. Quite a day.

Where Things Get Confusing

Time passed. I visited the dentists at Northwestern who splinted my teeth, but things weren’t healing up the way they had hoped and after giving the splinted teeth a couple of months to set it was time to start thinking about how to repair the damage. The folks at Northwestern referred me to one of their oral surgeons. He sounded pretty good, but after checking with my primary care provider, I discovered that he wasn’t in my network. Now I figured that this meant that he wasn’t in my Humana HMO network. I had signed up with Humana through my work. However, it turns out that she was referring to my IPA network. When I selected my primary care physicians, I had unwittingly opted into a sort of sub-network called Resurrection Preferred that contracts with Humana to provide all of my care. So in order to see an oral surgeon, I had to start with one of their providers. As it turns out, Resurrection Preferred has only two oral surgeons to select from. So after some back and forth with my primary care doctor, I made an appoint to meet with him. This was the end of January. The oral surgeon entered the exam room with his scrubs on and wearing one of those head-mounted lights like a spelunker. He looked at my mouth, the X rays I had brought with me, then asked, in so many words, what I was doing there. What I needed, he said, was a good restorative dentist to “quarterback” my care. Because of the extensive and complicated nature of my injury, I would likely have “one good shot” at achieving a good result. He recommended a particular dentist who could coordinate all aspects of my care including root canals, bone grafting, and tooth implantation.

So okay. There are no restorative dentists in my IPA network, let alone this particular one. After weeks of lobbying Resurrection Preferred and getting testimony from their oral surgeon, I finally got permission to visit the suggested dentist, thank goodness. I meet with him. He seems fantastic. He comes up with a plan to help put my mouth back together and submits it to the IPA. Negotiations ensue. The IPA offers to pay for a small fraction of his estimate. More back and forth. Then negotiations stop. Humana, the big insurer, steps in. I have heard from Resurrection Preferred that taking over dental claims was Humana’s idea. I have heard just the opposite from representatives at Humana–that Resurrection punted to them after my claim became too costly. Whatever the case, my request for care was suddenly in Humana’s realm and they decided to take a wholly different tact. They denied the dentist’s treatment plan because he was “out of network.”

Out of Network??

To review: when I left the dental team at Northwestern, I went out of my way to way to see an oral surgeon who was in Resurrection’s network. He referred me to a restorative dentist. There are no similar practitioners within the Resurrection network so after much finagling, I am able to see this person that the Resurrection provider recommends. But when Humana takes over, suddenly the network changes. So the expectations about who I am supposed to be consulting with changes. Never mind that months and months have passed and a definite plan has been arrived at. Casts of my teeth have been taken. An endodontist has been consulted who has done testing to see which teeth need root canals; I can no longer be seen by her either. Now that Humana rather than Resurrection is overseeing things, I am expected to change everything midstream. This was May 13.

So fine. I figure I am stuck. If Humana is only going to consider reimbursing someone who is in their network and they actually have providers capable of handling my case, so be it. I will meet with someone on their list. That the dentist who had been working with me up to this point decided to bail, explaining that he had already expended too much time and energy on my case, with little promise of proceeding: this also influenced my thinking. I reach out to the same Humana representative who had told me that my dentist was out of network and ask for a list of in-network providers. She faxes me a list of oral surgeons. After some research on my part, I discover that indeed a few of them do specialize in restorative work. I select one from my alma mater, UIC, who seems to have a good reputation and call to set up an initial consultation. I actually end up speaking with him over the phone, and when he hears I have Humana, he advises me to make absolutely sure that he is considered in network; there have been issues before. So I call Humana back, and again speak with the woman who faxed me the list. She confirms that this doctor is indeed in their network. However, she explains that in cases such as mine, where Humana has taken over from the IPA, typically they will only cover “facility fees.” They will not be covering “professional fees.” But, I ask her, won’t the vast majority of my expenses be professional fees: whatever the dentist charges for the root canals and implants, for instance. Silence on the other end of the line. What should I do if I want to get the professional fees covered? She said that I should speak with Resurrection Preferred, the IPA. At this point, I’m pretty sure I asked her if she was kidding. I may have cried a little bit, too.

Inside Voice

When the dentist I had been working with decided to drop me–and I entirely understand this decision; his staff had put in many hours in phone conversations and emails with Resurrection Preferred with little to show for it–I asked for all of their correspondence with the IPA. A large portion of the dealings were with one person. In her emails, she comes across as both helpful and exasperated with the bureaucracy of her organization. I decide to try to phone her directly rather than just speaking with whatever claims expert is in the office as I had been. She is out of the office and I am directed to her voice-mail. Later that afternoon I get a call back from her. Amazingly, she is on vacation on the west coast but felt that because the way things have turned out and all of the time that had passed that she should respond quickly. She agreed that the current situation is unreasonable and that my best course of action was to lodge a formal appeal of Humana’s denial of coverage. When I mentioned that I was frustrated and considering hiring a lawyer, she intimated that this probably wouldn’t go very well. She strongly suggested that I enlist the help of my human resources representative and try to keep working within the system. Perhaps a bit naively, this is what I have decided to do. In typical cryptic fashion, Humana has sent me a letter stating: “we are currently doing research and and will send a decision letter within the required timeframe” without actually stating what the required timeframe is.

The Mouth

In the meantime, my teeth structurally are just as they were immediately after the accident occurred. Plaque has formed around the wire splint and I have a lot of gingivitis as a result. Most of the remaining front teeth have “died” as a result of the trauma and may or may not be salvageable with root canals. I can’t bite down on anything. The fractured tooth still has an exposed nerve making brushing difficult. I speak with a bit of a lisp and look like an old school hockey player. Though none of this constitutes the end of the world, it is awfully inconvenient. And because the issue is right out in front of me at all times, I get a lot of questions and a lot of comments. I smile less, and I wonder what people are thinking of me as I speak.

Moving Forward

So rather than simply waiting for Humana to make their decision, I thought I would write about what has been going on and to get some input from you out there. Have you been through anything similar? What would you suggest I do? I plan to research the relationships between “major medical” insurers like Humana and the small IPAs that they contract with. How do they typically reach decisions about who covers what? I am also  interested in issues of physical appearance. Have you suffered an injury that left you disfigured, if even in a small way? How did it affect you? What did you learn from it? Finally, I will be exploring my love of urban cycling and my continued obsession despite the sting. For those of you wondering why I do not have a lawsuit pending against the city given that roadway conditions led to my accident, read here and here. I was not in a bike lane meaning that, according to a ludicrous legal precedent, I was a permitted but not intended user of the road.

I would appreciate any and all feedback and will be writing more soon. Thanks!

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About jkasbury

A guy with busted teeth fed up with his HMO.
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24 Responses to What Happened

  1. Shawn Greene says:

    I knew this would come out at some point! “speak with a bit of a lisp” HaHa!
    Seriously though, you have done a great job here. I know it will all turn out fine.
    Just think about it this way; if you had received perfect provider care you would not have been provided with this great opportunity to write about it.
    Feel free not to post this if it is moderated.

  2. Mike Schwab says:

    I would give Lawyer Jim (specializes in bicycle accidents), With him on your side, perhaps complaining to the department of insurance (you should be able to be cover by providers on the Base policy and ANY subsidiary policy). Also, since the roadway was at fault, they should be able to file a claim against the officials in charge of maintenance of the bridge. Due to Boub vs Wayne Township, the government entity would be immune but not their officials.

    • jkasbury says:

      Thanks for your advice, Mike! I already consulted with Jim but did not know about the Department of Insurance. I will definitely look into contacting them.

  3. johnstoner says:

    Holy shit, that sucks. You got sucked into the complications of their fine print/business model/crap. I didn’t realize there were that many land mines to step on.

  4. T.C. says:

    This is so outrageous. I have no real advice, other than to get a lawyer just in case the run-around continues.

    I think you’ve got the right idea starting this blog and hope that it brings help. You are doing society a tremendous service by posting the details of your crash –due to conditions the City of Chicago is well aware of– and your battle with Humana.

    I’m not sure what media/internet attention will produce in terms of results for you, but I want to find out.

  5. Michelle Gregorek says:

    This came to my attention via the CCM forum. Sorry, I have no advice for you, but wish you the best! The picture of the tire in the catch made me catch my breath! Had the same instance put it was my back tire in the side of an unused railroad track. It is amazing how quick your bike can come to a dead stop. I pray you get the care you need.

    • jkasbury says:

      Thanks, Michelle. Yeah, you are right about abrupt stops. There are some tracks like the ones you mention that I go over on Goose Island all the time, and ever since my accident I try to make the angle as perpendicular as possible and hold my breath. Was it Gin that posted the link on the CCM forum? I posted a discussion on chainlink but did not think to place a posting with CCM.

  6. So sorry to hear that this happened. It’s a nightmare I think of every time I ride over a metal grate bridge

    It’s very good to have Jim on your side!

    I asked a Cleveland cycling lawyer friend:

    “Horrible story. The denial of coverage needs to be made in “good faith,” grounded in the agreement and action of the parties. From a cursory reading, I think she should send letters to Humana and Resurrection that there she is frustrated by their actions and decisions and getting worse as a result. If she is not able to resolve and receive coverage for service under the insurance agreement, she will need to talk to a lawyer regarding their conduct. As for the street interpretations and Boub decisions, that’s one of the reasons we initially start a pothole reporting process, so that the city has notice of road damage and the potential for injury. That’s still an important service to provide cyclists (and motorists).”

    Sorry he made you a she. Another thing, send all your letters certified mail and add “CC:Legal Brief” at the end! Keep fighting, you’ll get back that bangin smile and get lots of folks thinking as well!

    • jkasbury says:

      Thanks, Jody. I like the name Jody. It was my nickname growing up. Anyway, I appreciate what your lawyer friend in Cleveland said. I have filed a formal appeal of my denial of coverage with Humana and essentially said what was suggested, but I think that it makes sense to send the same to Resurrection as well, along with the cc: legal brief, as well!

  7. Mike Schwab says:

    Maybe add a CC:Michael Moore, Flint, MI too.

  8. CJ says:

    Your story was forwarded by a friend of mine. Look into whether you have any media personas who do David vs Goliath stories. I know we have one in our area and I can’t imagine a media areas as big as yours would not. This would make a good story on a lot of levels for someone like that and they could do some of the heavy lifting (and in this case the fact that you have been trying to work this through “the system” and not sue could be on your side from a human story perspective).

    • jkasbury says:

      Thanks for the advice, Christina. I have been looking at media personalities but not strictly with the David and Goliath framework that you mention. Entering such a qualifier in the search-string (so to speak) might help.

  9. Gin says:

    Joe.

    I am sickened by the hurdles you are facing to receiving care, as well as being caught up in the horrible aftermath of Boub vs. Wayne Township. We need to address this liability issue, and perhaps better educate cyclists about the “two tiered” system.

    Have you contacted Ben Joravsky at the Reader or John Greenfield who does bicycle reporting for many local pubs?

    You might want to show up at the Bike to Work Week rally downtown this Friday morning with a big sign saying “Ask me about losing my teeth while biking on a metal grated bridge downtown. . .” or something more pithy. For, while we talk about adding bicycle facilities to some streets, we need to remember that the street network *is* the bicycle network.

    Gin

    • jkasbury says:

      Thanks for all your help, Gin. I just sent emails to John Greenfield and Ben Joravsky. I will do my best to make it to the Bicycle To Work rally this Friday, too. One of the silver linings to all this should be that I get more plugged into the bicycling advocacy network in Chicago, for sure.

  10. Kathy Schubert says:

    To everybody who thinks about riding on the LaSalle St. bridge: Ride in a straight line as fast as you can or ride on the sidewalk. If anybody objects to you riding on the sidewalk, tell them about this accident and the one I had by riding NOT on a straight line. Or, take Wells St. if you are going South or Franklin St. if you are going North.
    To Jkasbury: Try the Sun-Times “The Fixer”

    • jkasbury says:

      Indeed, Kathy. I was moving from right to left in order to avoid a dangerous seam at the north end of the bridge when my front wheel slipped between the grates.

      Thanks for all of your efforts to make this and all the Chicago River bridges safer for cyclists.

  11. Suzi Wint says:

    Joe – I had a similar dental story due to a traffic accident. I was walking and was hit by a motorcycle and had to negotiate all the same B.S. you are right now. Two bone grafts to my upper jaw, two implants, some repairs to broken teeth and a couple years of orthodontic work. I just joined Chainlink after reading your blog, mostly because I have a few tips – both in terms of how to get through the insurance, and an EXCELLENT dentist who managed all my stuff and did many of the surgeries. He works on professional hockey players, so you know he knows his stuff. Their office had a lot of experience with insurance, mostly because their manager worked for an insurance company previously, and they were very willing to work with me on payment plans for the bits I had to cover. Oh – and they are in town – ironically, I think you can see the bridge from their office.
    Not sure how to be in touch with any details, but I’ll have a look once I’m officially approved as a member.
    My most valuable piece of advice: LOTS of patience.

    • jkasbury says:

      Thanks, Suzi! Glad to hear that your dental issues were resolved even if it took an age. It sounds like you have a lot to teach me. My email address is: jkasbury@yahoo.com. Feel free to write any time. Would love to hear from you!

  12. purple square says:

    http://www.activetrans.org/crashsupport for pedestrians and cyclists. You don’t have to have been hit to be in a crash.

    • jkasbury says:

      Don’t I know it. I called the hotline the day after the accident just to report it. Very supportive guy spoke with me then followed up throughout the week.

  13. Rebecca Resman says:

    I’m so very sorry this happened to you. I am in charge of the Crash Support Hotline at Active Transportation Alliance. I remember speaking with the Crash Support Hotline Volunteer when you originally called. I wish we could have done more for you. I’ve actually thought about you on a few occasions and wondered how everything turned out. The journey you have had is heartbreaking, but I am amazed at your resourcefulness and your ability to maintain your sense of humor. Your blog is very well written. Thank you for sharing your story.

    The Boub vs Wayne Township case is an outrage, but the treatment you have received from the insurance company is just plain evil. I’m glad they are now going to cover it, but the fact that they waited this long and made you jump through so many hoops is disgusting. Only when faced with a threat of media attention, do they buck up and decide to provide you with the coverage that you and/or your company has paid the premiums on.

    If you are still working with Jim, I’m sure he is all over it, but there might be a legal opportunity here against the insurance company if the delays in treatment you had due to their process complicated your recovery.

    • jkasbury says:

      Thanks for your support, Rebecca. And thanks to everyone at ATA, especially the crash support hotline volunteer who took my call. He was very sympathetic and took pains to follow-up with me later than week. You all provide a very valuable service.

      It has certainly been a real bureaucratic adventure for me, but also a rewarding lesson in the power of the printed word. The pen is mighty–or should I say: digital media is mighty. I am also very grateful for the tremendous support and good advice that has come my way as a result of publishing this blog. It’s far more than I hoped for. Finally, I have been overwhelmed by the vitality and enthusiasm of the Chicago cycling community. It’s a phenomenal group.

      In the next few weeks, I should finally begin working with someone sanctioned by my insurer. At that point, I will see if there is a case to be made for damages done by the delay.But really all I want out of this is teeth that work and look half-way decent.

      Thanks again for your comment.
      Joe

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