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Re: [IP] Michael, what do I do?

> Michael, I have an insurance dilemma I need help with.  Seems my
> insurance has a limit on how many glucose test strips I can get per
> month.  That limit for an insulin dependent diabetic is 200.  My
> pharmacy has been giving me 250, but I'm afraid that they may cut me
> back to 200 since I'm not sure they're being paid for all of them. 
> My endo tried to call in for 300 strips per month which started this
> whole business, the provider called me and said that my contract
> would not pay for that many test strips.
> I called the insurance company and they told me that according to
> the contract with my husband's employer, they will only pay for 200
> test strips per month.  They told me it was specified in the
> contract.  I called the Human Resource person at my husband's
> employer and she told me that the contract did not specify any
> amounts, it just said that Medical Equipment was covered at 100%.

Seems that the Insurance Company is practicing medicine WHICH IS 
AGAINST THE LAW. You have a legitmate gripe and you WILL get your 

First -- what state do you live in??

> I called BC/BS back and the lady explained that their Benefit
> Adminstration sets maximum amounts to be covered and, even though
> it's not spelled out in the contract
That is the key. If it is not mentioned as excluded in the contract 
then is therefor INCLUDED. If a doctor writes a prescription that say 
you should test 10 time a day then they must supply the necessary 
strips. Get you doc to write the prescription so it says "Test strips 
for bg testing 10x each day" .... or whatever frequency you desire.

Since you are unable to negotiate the terms of the policyand 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 but DON'T give up, 
don't take no for an answer. 

> that's what's covered and if
> my husband's employer wanted more covered they could have added a
> rider to get more coverage.  I asked her if they were told that, and
> she said she didn't know, that that was all handled by the District
This is BS -- again, if it is not spelled out in the contract, it is 
tough for them...

> Do you know if anything
> I can do to solve this problem?  The lady from BC/BS said they CAN'T
> give me more than what is specified in the contract, 
Ask for a copy of the contract and ask specifically what page, 
paragraph, etc... that is says 200 strips. This must actually be in 
THE CONTRACT that was agreed to and signed by both parties, not some 
supplementary internal guidelines -- which is pure bs

> even though the
> actual contract does not spell out a covered amount.  Thanks much,
__________________^^^^^^^^^^^^^^^^^^^^ if this is true you have them
by the "short hairs" so to speak. Time to start threatening. Call the 
office of the "Medical Director" in you state and explain the problem 
and ask if they can handle it or if it is necessary for you to go to 
the insurance commissioner. Be prepared to go to an attorney if 
necessary, but this is one you can win.

> Michael.  Boy, do I HATE insurance companies, even more than I HATE
> sandwiches!

Me too! I've had my fill of insurance problems and I have absolutely 
NO sympathy for them when it comes time to stick it to 'um.
> RoseLea and Max... back to fighting the insurance company!
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