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Re: [IP] Insurance Denial


It is not unusual for the insurance companies to deny coverage initially.
Insurance companies are in business to make money.  It is to their advantage
to deny coverage and hope the person will quietly accept that decision.  Do
not be that person.  Become the biggest pest and make the loudest noise
possible.  You will need an organized plan.  Here are just a few suggestion:
    1.  Write a letter to the medical director of the insurance company.
Many decisions are made by clerical personnel.  Include information
regarding the benefits of pumping and the long term potential cost savings.
( A useful article is from JAMA, Nov 6, 1996 - Vol 276, No. 17, page 1409.
Your primary md or your endo can help you get a copy)
    2.  Dispute the reasons for denial by pulling lines out of the insurance
contract.  Where does the contract state that only those 12 and up or in
poor control should have diabetes pump coverage.
    3.  Have your primary care MD and you endo both write letters stating
that in their opinion a pump is in Eric's best medical interest.
    4.  Keep copies of everything and log any phone conversations.  Even
send things by registered mail if info continues to get "lost".
    5.  Enlist the help of one of the pump companies.  All are good at
dealing with the individual insurance companies.  MM was very instrumental
in getting a DME cap removed for me.
    6.  Check to see if you have a DME cap and if so if there is a clause to
get it waived.
    7.  If your insurance is through a job, enlist the help of your local
human resources supervisor.  Get them to write a letter stating they agree
with Eric's physician regarding the need for a pump.
    8.  If things start to look bad, contact your state Insurance
    9.  Call and check on the status of the review every few days.  The more
noise you make the better.

These are just a few of the many ways to deal with these companies.  The
most important thing to remember is to not stop your fight.  You know what
is in the best interest of your child.  I got lucky in that after my first
two rounds of dealing with UnitedHealthcare, and I got a reviewer that was a
pumper.  I got approved very quickly after that.

Good luck
----- Original Message -----
From: Lisa Abrahams <email @ redacted>
To: <email @ redacted>
Sent: Friday, April 06, 2001 12:43 PM
Subject: [IP] Insurance Denial

> My six year old son Eric was just denied coverage for an insulin pump by
> Blue Cross of North Dakota. The denial came after they conveniently lost
> the request and had to have everything resubmitted.   The request was
> denied because their criteria say you have to be at least 12 years old
> and he is too well controlled.  I can only laugh at their reasons.  He
> is well controlled because we give him 3-6 injections a day.
> I have been told that 2 children under the age of 12 have had pumps
> covered by this insurance company.  Does anyone know these kids?  Any
> other suggestions?  Thank you,   Lisa, mother of Eric 6, diagnosed Sept.
> 2000.
> ----------------------------------------------------------
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