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Re: [IP] insurance
> Hello, We just got new insurance and they do not want to cover
> anything, they are trying to get medtronic to reduce their prices
> and if they don't then nothing will be covered. Does anyone know of
> any insurance that I could get that would cover pump supplies? I
> used to have Blue cross and they covered everything but my husband
> changed jobs and we cannot afford to pay for blue cross on our own.
> I'm so frusterated right now. Carol from Michigan
A bill authored by John Engler was signed into Michigan law in 2001
requiring insurance companies to cover diabetes supplies. I don't
know the specifics, but I would be shocked if it contained and
exclusion for pump supplies. Unless you are under union contract,
which has a different set of rules, if your insurance covers ANY
diabetes supplies or prescription drugs, then they generally must
cover pump supplies as well unless there is a specific exclusion
written in to YOUR COPY of the contract of insurance (which I
seriously doubt) that is allowed by the new state law. Don't take no
for an answer. Do the usual things.
First -> get WRITTEN denial so you really have something to beat them
up with. If they balk, tell them plainly that you plan to appeal and
need the letter of denial. There are usually several levels of appeal
within the company, then an appeal to and independent outside board
and/or the insurance commissioner's office.
Most insurance policys are written in a manner that says all normal
medical expenses are covered unless experimental or specifically
excluded. Since you are unable to negotiate the terms of the policy
and must accept what they provide for policy language, the courts have
taken a strict interpretation of the language to mean that if the
insurance company forgot to mention something, they are obligated to
provide it. Bottom line, pumps and supplies are covered unless there
is specific language to the contrary. You may have to appeal, you may
have to involve the insurance commissioners office or state department
of labor in the case of a union sponsored medical plan, but DON'T give
up, don't take no for an answer. If prescription diabetes supplies of
any kind are covered, then all the pump supplies are probably covered
as well as described above.
You will also see a link there about the
"Things insurance companies don't want you to know".
This contains a wealth of information about how to fight with them and
how to win.
There must be specific policy language written in your policy as the
basis for denial. Insulin Pumps and their supplies are conventional
therapy for diabetes that can be prescribed by any physician.
All that should be required for coverage is a prescription from your
physician and a letter of medical necessity The insurance company can
not contravene a doctors orders for treatment unless those orders are
patently unreasonable and inappropriate.
What they will attempt to do is divert you away from the issues about
the "contract of insurance" and "practicing medicine" with arguments
about age, hbA1c's, their so-called internal policies, etc.... ALWAYS
bring the focus back to the contract and the doctors order.
Consider talking to your attorney and the insurance commissioners
office about the insurance company not living up to it's contractual
obligations to provide medical care. Insulin pumps have been around
for over 20 years. They are standard treatment for diabetes care and
represent the "gold standard" for such treatment. Is there a
ligitimate reason for refusal of care that is contractually based?
At some point in time after you have been reasonably polite, start the
appeals process. Even if this process is denied, continue at that
point to contact the medical director for the insurance company and
re-start the process. They'll eventually cave in. Keep up the faith,
attack, attack, attack.....
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