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[IP] Union Insurance Hoop Jumping

In a message dated 5/12/99 5:55:37 PM Eastern Daylight Time, 
email @ redacted writes:

<<  I know the union 
 contracts are quite different from a standard insurance contract. The 
 hoops you jumped through things you did to convince the powers that 
 be to pay would be useful information for the next "victim".
 Michael >>

		I'd be happy to do this.   As our union explained to us, 
because our benefits are based on contract negotiations between the companies 
and the members, basically, we were not able to use the mandate in our State 
(NY-Sweeney Law) to make them pay for the pump.  They basically informed me 
that NO a pump was not covered.  I looked over our benefits booklet, which by 
the way was printed up as of June 1997 and we JUST received in MARCH of 
99!!!!!  I could not find anywhere in the booklet that stated that insulin 
pumps were not covered.  There was however a list of things that were 
excluded, and at the end of this list it basically said that there were other 
things not on the list which were not covered and it was at the discretion of 
the trustees as to whether or not coverage would be granted.  I had to file a 
formal appeal.  I submitted a letter from our endo, our pediatrician stating 
the dates he was dx'd with the asthma and the diabetes, an excellent letter 
that I borrowed myself from someone online who had posted with a similar 
situation.  I adapted the letter for our own situation and basically spelled 
out all of the reasons WHY Steven needed the pump.  According to them being 
diabetic itself is not reason enough!!!! Can you imagine what stupidity??  
Anyway, I also submitted copies of his labwork showing A1c's which were 
steadily rising, and I also included a schedule of fees from our local 
hospital highlighting the daily fees for pediatric ICU.....($1,450 per 
day!!!).  Our endo came up with that idea.  He said Steven was definitely 
heading for a stay there and they should see that a couple of days in PICU 
would well exceed the cost of the pump.  I was advised that IF we were 
approved they might pay a portion of pump and supplies from the beginning of 
my inquiry, and I was expecting just that.......However, when we received 
approval, we were covered at 100% for both pump and supplies!!!!   I was just 
too excited!  The only thing I have a bit of a problem with is the fact that 
if I use one of their listed providers, I can get the supplies shipped as I 
need them, BUT, none of the providers carries pump supplies so we will have 
to buy them and submit the bills......I know that will be difficult for us to 
lay out, but I'm sure we'll figure that one out too.  

	Basically, if you have union insurance it is not covered under State 
mandates or the State Insurance Commission, The Department of Labor is the 
body which oversees the various plans which are considered self-insured.  
Union plans fall under this group.  We were told from the start that others 
had tried to get pumps covered and were denied.  We were the FIRST to be 
successful!!  I would think that being thorough and informed was what pushed 
us along.  We proved to them that we knew what we were talking about and we 
had all the proof they could ever want ready from the start.  I think we kind 
of bombarded them with packets of information.  I had articles about children 
on pumps, articles from clinical journals pertinent to our situation, 
basically ANYTHING I could think of to wake them up.  I hope that this makes 
it a little easier for the next person who tries.....I hope that would be the 
case.  If anyone has any questions about this type of insurance and 
strategies to overcome the denials feel free to e-mail me anytime, I'd love 
to help.

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