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The HMO Battle

The high cost of health care can become even more of a strain on the wallet if your health insurance denies your claim or refuses to pay your medical bills.

The Early Show medical correspondent Dr. Emily Senay has some advice to help get you what you deserve.

Speech therapist Debra Moran of Winfield, Illinois needed surgery to fix a painful nerve condition in her shoulder.

"The pain got to he point where I couldn't lift a fork or a glass to feed myself," says Moran.

But her HMO refused to pay for a new surgical technique to fix the problem. They insisted that an older, riskier procedure would suffice.

"I had a choice of getting better or a choice of being paralyzed, a third of a chance of being paralyzed," says Moran.

With her doctor and independent specialists supporting the decision, Moran decided to have the $94,000 surgery she needed and paid for it herself.

"We took out a loan against my husband's 401K. We maxed out our credit cards and my mother-in-law paid a huge chunk of it as well," says Moran.

Debra sued her HMO. Four years and a mountain of paperwork later, they still refused to pay. Her case became a landmark for patient's rights. This year, the case was finally decided in her favor by the U.S. Supreme Court.

It was an important issue of who decides whether you get medical care — a doctor or an insurance company," says Daniel Albers, Moran's lawyer. "We felt strongly under state law that the doctor should decide that. It was David versus Goliath and we had the right stone and hit them in the head and we won this one."

"God forbid there's another insurance issue I'll have to deal with," says Moran. "I'll just say, 'I'm Debra Moran, I fought my HMO all the way to the U.S. Supreme Court, now are you going to pay this bill?'"

Moran won a battle, but not the war. There are no comprehensive legal guarantees for patient rights yet. But, the lesson here is persistence really pays off if a claim is denied.

Dr. Senay says don't take no for an answer, no matter how many times you hear it. In most cases, your doctor is your best ally. It's usually a doctor's failure to make a good case for treatment that is the weakest part of the patient's argument for coverage, so make sure your doctor weighs in early in any dispute.

In many states, cases can be arbitrated outside the insurance company by a process of independent review. If you can't get one, you should consider legal action.

Of course there will be bureaucracy that you need to navigate through. Most of us know how frustrating it can be to undergo the recorded messages and the endless waiting on the phone when we try to argue our case. But once you find a name and an address, put everything in writing.

Dr. Senay strongly recommends being persistent and keeping good records.