Lump Sum


Joel Feldstein went to the doctor because he thought he’d strained a throat muscle and instead learned he had a rare cancerous tumor on his esophagus. “They said I didn’t have years,” remembers Feldstein.

Three years later, Feldstein, 55, is endlessly grateful to Manjit Bains, the thoracic cancer specialist who treated him. “That surgeon is a tough cookie with a heart of gold and a twinkle in his eye,” says Feldstein. “I wouldn’t be here today without him.” The ebullient survivor also beams about his cousin, a physician who advised him to seek out Bains at Memorial Sloan-Kettering. “It’s just the kind of person he is,” Feldstein says. “If his dog was very sick, he’d go out and make sure the dog got the best care, too.”

But the former stock trader, who has eased his way into a less stressful position at his firm since his illness, has no such kind words for
his HMO, CIGNA HealthCare of New York. CIGNA refused to fully pay for the treatment that saved his life. Although Feldstein’s surgeon said his cancer would likely kill him, and his treatment was a quick regimen of unsuccessful chemotherapy followed, three months after his first visit, by a grueling six-hour surgery, CIGNA argues that his situation didn’t qualify as an emergency. The company says Feldstein should have sought treatment with one of its doctors and, since he didn’t, refused to pay in full for the “out-of-network” treatment he chose.

“[Mr. Feldstein] clearly did not present with any of the immediate life-threatening situations,” such as excessive bleeding or airway obstruction, CIGNA’s then medical director, Charles Davis, wrote in a November 1997 letter denying complete coverage for Feldstein’s medical expenses. The company did agree to cover Feldstein’s care as out-of-network, paying a substantial portion of his total costs, which came to about $100,000. But CIGNA’s decision left Feldstein to pay some $13,000 in medical bills on his own.

Feldstein did ultimately get CIGNA to agree to foot the entire bill of seeing his physicians at Memorial Sloan-Kettering as of July 1997. But he was unable to prevail upon the company to pay the $13,000 debt he had already incurred at the hospital. It’s this inconsistency–perhaps more than the debt itself–that really irks him. “What they’re doing is throwing me a bone,” he says. “They’re admitting they’re wrong. But then they’re still refusing to pay the leftovers.”

Feldstein, who continues to petition the company for what he admits is a “modest sum,” can’t imagine how he could have acted differently. “When you hear you don’t have years, you’re not thinking of shopping around for someone within the network,” he fumes. “I was just too shellshocked to call anybody.”

Furthermore, Feldstein says that when, after he had already been treated, CIGNA finally provided a list of surgeons for whom the company would have provided complete coverage, none were as well qualified as Bains to treat him. His extremely rare form of esophageal cancer affects 50 to 100 people in the country per year. “They wanted me to go to someone who hadn’t ever treated a case,” says Feldstein.

Feldstein’s team of doctors at Memorial Sloan-Kettering coauthored dozens of articles on the cancer, which, they say, “usually proves rapidly fatal.” His surgeon, Bains, engineered Feldstein’s remarkable recovery with accurate diagnosis, aggressive chemotherapy, and the surgery, in which the large tumor was removed as well as parts of Feldstein’s esophagus and stomach (“my stomach is now in my chest!” he proclaims proudly).

Bains even wrote to CIGNA on behalf of Feldstein, insisting that his care “could not be duplicated at other centers.” When CIGNA then continued to balk at paying for the entire cost of care provided by Bains and others at Memorial Sloan-Kettering, Feldstein recruited a personal attorney, the state attorney general’s office, and the state department of health to help him make his case. (Feldstein also wrote to President Clinton, Donna Shalala, and senators Moynihan and D’Amato, among others.)

It was a counselor at the State Department of Health who ultimately helped convince the HMO to bend slightly in its position and pay in full for all care Feldstein currently gets at Memorial Sloan-Kettering. From now on, he will only have to pay the standard $10 copayments when he goes for follow-up CAT scans and blood tests to see if he’s still cancer-free.

It’s a weight off his mind. But Feldstein, who is awaiting the results of a biopsy of inflamed stomach tissue detected in a recent test, says he still thinks the company should pay the $13,000 bill for his initial treatment. “I’m trying to prepare myself in case the cancer returns,” says the persistent Feldstein. “I didn’t quit on my illness and I don’t intend to go away now.”