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Re: [IP] insurance denied - longish reply

>The pump is supposed to be covered 90% under durable medical
>equipment along with the supplies.

Here are my suggestions... take what you can use.

-try your darnedest to get something in writing as to exactly why this
was denied. They will probably not want to do it, but keep insisting on
talking to a supervisor, and their supervisor, etc. Document everything
- write down the names of everyone you talked to and the date and what
they told you.
-you may want to have your doctor talk them as well to see what reason
they will give him about why it was denied.
-how did you find out that pumps are covered 90% under durable medical?
is it in your plan somewhere? try to get that in writing too, it will
probably be VERY difficult but try, again you will likely have to go
through MANY supervisors. In our case, they did not want to give us
anything in writing because they covered pumps but only if certain
"rules" were met, like at least 3 shots per day, etc. They would not
want to put those rules in writing because it would be very bad,
legally, for it to look like they were "prescribing" who gets pumps.
-call the insurance people and talk to someone "higher up", ask them
what the grievance proceedure is. Even if you already know it, make sure
they know that you want to know, and why, and that you intend to file
-get the pump company people to talk to the insurance company. They want
that $5000, and if you make them understand that they won't be getting
it unless insurance pays, they will do lots to try to work with the
-file a grievance and/or appeal. Include a copy of whatever you have
showing that pumps are covered. Your doctor probably already wrote a
letter of medical necessity to give to the pump company. Include a copy
of that. Also you may want your doctor to write another note addressing
whatever reason they denied it for. Include your own letter stating
several things: the doctor wrote a prescription for the pump because he
feels it is medically necessary; if they don't fill it they are acting
in bad faith and/or practicing medicine without a license; if they are
denying it based on age say something about age discrimination; if they
don't correct this in a timely manner you will be contacting the state
insurance commissioner and your lawyer.
-if they still deny it, follow through and file a complaint with the
insurance commisioner. Include copies of EVERYTHING. The more stuff you
can give them, the better. Send a copy of it to the insurance company so
they KNOW that you have done this. In our case this is what finally
worked. The threat of going to the commissioner did not work as it has
for others here. Actually contacting the commissioner did work. We did
not even hear back from the commissioner yet, and the insurance company
started sending more payments!
-I guess if this doesn't work you might actually have to contact a
lawyer - assuming that you are located somewhere that it is legal to
sue... if they are an HMO, many places you can't sue them. :( I think
Michael will tell you that pretty much everyone on the list with this
problem eventually got the pump paid for without having to take this
good luck,
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