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El Cajon veteran sent to collections after conflicting insurance decisions

Posted at 4:40 PM, Oct 03, 2019
and last updated 2019-10-04 20:02:52-04

EL CAJON, Calif. (KGTV) - An El Cajon man says a new spinal procedure changed his life, but the Army veteran is now locked in a battle with his military health insurance plan which refuses to cover it.

Ronald Maddern says he can't understand why TRICARE, his secondary insurance, would deny coverage of the procedure after his primary insurance, Medicare, agreed to cover 80 percent of the cost. Both insurance plans are run by the federal government.

"Makes me feel like a second-rate citizen after I served in the military for so many years," he said.

The denial by TRICARE left him with a bill of $4,756.

Maddern had the Vertiflex procedure in 2017 to treat spinal stenosis, which had largely confined him to a wheelchair for 17 years. Maddern is now able to walk with help from a cane for balance.

"It was a drastic success," said the 71-year-old. "My quality of life now is very, very good."

The procedure, developed by a Carlsbad company, was approved by the FDA in 2015. It has been performed thousands of times across the country, said Maddern's surgeon Dr. Michael Verdolin.

"It is extremely frustrating that one arm of the government says yes and the other portion, really the pinky, says no," he said.

In a letter of denial, TRICARE argued Vertiflex is an "unproven procedure," despite its FDA approval.

"There have been 15,000 cases across the US. It's been cleared for use," Verdolin said. "There is no question to be asked about its efficacy."

TRICARE did not immediately respond to requests for comment by 10News.

Ronald Maddern's insurance case is now before an administrative law judge. He's hoping the judge's ruling will convince TRICARE to conform its benefits with other federal agencies, so more veterans can get the procedure.