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[IP] GOOD NEWS IN FIGHT WITH INSURANCE
This is rather long so delete if you'r not interested. But it shows that
I have a grievance with the HMO I joined going on for a year now. A
little back ground; I am on disability social security and medicare. I
joined an HMO for the added benefits you can get with some of them that
take medicare people. When I joined I asked if they would cover the
infusion sets & syringes. They told me yes under durable goods & a $
figure they would cover up to.. Three different people in the
organization where asked and all said the same thing. Then last February
I ordered for the first time and then they told the pharmacy they had
made a mistake and would not cover.Then I did the following:
1. filed a grievance with them
2. there answer was medicare does not cover it. I reminded them that I
had asked if they would cover and said yes.
3.appealed grievance and went before their board of quality control
people and they decided to cover me for a year and the grievance was
sent to The Center for Health Dispute Resolution (CHDR)
4. CHDR agreed with there explanation that medicare does not cover and I
just tossed it back to them that the deal was they told me they would
cover not if medicare covered or not.
5. Anyway it finally got to an Administrative Law Judge Hearing which
was suppose to be 2/2/99.
TODAY 1/14/99 the HMO called me to say they would be covering me for the
supplies. I said send it to me in writing and I will let the Judge know
the case is settled. Also in my research to fight them I got the laws my
state (Florida) has for HMO's to operate in the state and the law stated
they must cover diabetic supplies if the doctor had said it was a
necessary supply. Sorry for the length but I thought others might be
interest in what persistance and not taking the word of what we persume
are educataed professioals.can do. Leann "who lucked out".
Insulin-Pumpers website http://www.insulin-pumpers.org/