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[IP] "Durable Medical Supplies" and health insurers

I want to applaud Michael's primer about sticking up for our rights when
it comes to claiming coverage for insulin pump supplies.  He is right
on, and it bears repeating.


>> Date: Thu, 24 Jun 1999 10:31:31 -0800
From: "Michael" <email @ redacted>
Subject: [IP] Insurance Problems

> Please share any info you get to fight these insurance gorillas!!!!
Most insurance policies 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. 

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.

Use the wooden leg story and stand up for your rights. All that 
should be required for coverage is a prescription from your physician
and a letter of medical necessity That doesn't mean it will work, but
you must address the legal issues of the the policy language, age 
discrimination, etc.....

They may tell you that your hbA1c's are so good you don't need a 
pump, quite the contrary.  Good hbA1c's are an indication of a 
patient that works hard at control and is a GOOD candidate for a 
pump, not the other way around. They need to understand that (they 
do, but tell them again). Then again, if your hbA1c's aren't so good,
you can tell them how the pump will help them improve and how the 
improvement will help lower long term complications. See the 
improvement charts on the ABOUT page of the web site and the link to 
the user friendly DCCT explanation on the LINKS page. The majority 
of participants in the DCCT switched to insulin pumps because tight 
control was easier to achieve.

If all this doesn't work, 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. You must use all the 
economic arguments on reduced complications, cite the results from 
the DCCT, etc... and continue to point out that in the 
absence of specific language to the contrary, the pump should 
be covered under the policy. As a last resort, threaten taking 
the matter to the insurance commissioner (or state labor board 
if union) and tell them that the matter will go to your 
attorney. Remember that if you bluff, there is a small but 
slight chance you will have to back it up. They'll eventually cave 
in. Keep up the faith, attack, attack, attack.....

email @ redacted <<
Insulin Pumpers website http://www.insulin-pumpers.org/
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