I’d like to get you caught up on what’s happened since my last post:
PRE-TRIAL: I received correspondence dated 8-30-05 called a “Substitution of Counsel”. This stated that Insurance was withdrawing the appearance of a lawyer that I’ll call ‘E’ and ‘So-and-So & Associates’, and entering the appearance of a lawyer ‘N’ and Insurance on behalf of Insurance. (The appeal notice letter that I mentioned in my post #24581 - Sat Aug 27 2005 03:14 PM was signed by Lawyer ‘N’.)
Then I received a letter dated 9-12-05 from So-and-So & Assoc. This included their “Notice of Intention to Appear” which stated that they don’t owe anything because “The electrolysis performed in this matter was a cosmetic procedure and, therefore, not a covered benefit of the Pennsylvania Medical Assistance Program”. Also included was another “Substitution of Counsel”, withdrawing Lawyer ‘N’ and entering Lawyer ‘E’, a lawyer ‘M’, and So-and-So & Assoc. on behalf of Insurance.
12-13-05 TRIAL DAY: [Disclaimer: I think anyone who reads this post should keep in mind that, even though I am honest, I could be getting these details wrong due to the fact that I was extremely nervous and upset, my memory is not perfect, and there was a lot that the judges said that I didn’t understand. I’ll try to put this in chronological order.]
Lawyer ‘E’ (by herself) and I enter a room with a panel of three judges, all men. The judge in the middle (who reminded me of Colonel Potter from MASH), told me something about my not having a lawyer - that they don’t necessarily recommend this, and that they are not there to help me. I was really confused as to what his point was, and his no-nonsense disposition intimidated me. Hopefully this is something they have to tell everyone, and he wasn’t yelling at me.
One of the judges asked that anyone who would be offering testimony stand and be sworn in. I stood, but for some reason Insurance’s lawyer did not. They asked her if she was the defendant, and instead of just saying ‘yes’ she had a confusing answer that I can’t even remember. To me it seemed like she was confused.
I think she got to speak first. She pointed out that by my filing suit I didn’t go through the welfare system, which was the thing to do according to their correspondence. But the judges didn’t seem to find this fact to be important.
When it was my turn to speak I was asked to briefly state my complaint. So I used the same statement as in the first trial: "I have Polycystic Ovarian Syndrome and insulin resistance, both of which result in hirsutism, which is a male hair pattern on a woman. The insurance company’s definition of medical necessity says that they will cover a service that “will, or is reasonably expected to, reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability.”
A short time later the judge in the middle asked me to briefly say why I was there, but without saying why I was there. I’m sure I misunderstood him, but that’s what I got out of it. I was confused as to what I was supposed to say and scared of making them angry. Very hesitantly I told them that I felt I had already stated that. Maybe this is the place in the trial where they asked me how much money I wanted. I said I wanted $2550 for the electrolysis plus $83 for the filing fee. They said that they’re not the ones I would get reimbursement for the filing fee from; I’d have to do that on my own. ???
I was visibly shaking and the judges were actually going to wait for me to calm down before proceeding. I told them to please just go ahead because I had been shaking since the night before and I didn’t think that it was going to stop. The judge on the left said to me, “Can I give you some advice. You need to relax.” (Starting a week before the trial, I was getting headaches and chest pains from worrying, and my OCD was more painful than usual. While I was in the courthouse waiting room, shaking all over and rubbing my temples, I was wondering why I’m putting myself through this.) Unfortunately, when the judge said this, I started crying. Everyone was really nice about it, though. The judge on the right (who looked like Donnie from Even Stevens) went out to get some Kleenex, the girl working in the waiting room brought me some, and I think even the Insurance lawyer did.
The lawyer brought basically the same papers as in the first trial, and she made reference to either or both of the same points as then (see my post #23597 - Wed Jul 27 2005 07:31 PM, paragraphs # 6 and 7). She pointed out that the definition of what is considered cosmetic is “not limited to” the list of examples given, so therefore electrolysis could be included.
The judges asked lawyer E if she had any expert testimony. She gave them some information printed out from WebMD. I don’t remember what it said, but the cool part was that the judge on the right said, “So you get your definitions from WebMD and not from your policy?” (Near the end of the trial, one of the judges said that Insurance needs to get their policy clear.)
I handed the judge on the right copies of my gynecologist’s letters, the prescription from my PCP, the Insurance Definition of Medical Necessity, and a 5" X 7" photo of my disgusting beard, which I placed on top for effect. (This was hard for me to do, because young guys make me nervous since I worry that they’re judging me as being ugly. Now I was showing one of them exactly how gross I really am.) While he was looking through my papers, he said to the Insurance lawyer, “In my opinion, this is outrageous”.
One of the judges asked her (regarding the Definition of Medical Necessity), “If I had a disease which caused my arm to fall off, would the treatment of that be covered?” She said she couldn’t answer that. At some during the trail, one of the judges said, “Black is black, and white is white.” I’m guessing that he was telling her that, according to the Definition, electrolysis should be covered.
She brought out that there are alternatives to electrolysis, such as oral birth control. So of course I told them that I’ve started having Depo-Provera injections. She also said that my PCP’s prescription mentioned that my hirsutism was causing me “emotional distress”, therefore it is not medical in nature. Lame!
Towards the end of the trial, the lawyer said that Insurance had not received the electrolysis bill. I showed her a copy I had made of all my electrologist’s receipts. Plus, I had with me the credit card bills to match.
When it was over, the Insurance lawyer left the room first. My mother, who was in the waiting room, said that the lawyer looked disgusted and that she gave my mother a dirty look. (The lawyer had been sitting right behind us in the waiting room before the trial.)
POST-TRIAL: A few days later I received in the mail a letter signed by all three judges stating that I won! The Insurance company had 30 days to appeal, and guess what, they waited til the very last day to file. The next trial is supposed to come this summer.
