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Re: [IP] Insurance QuestionsProble

In a message dated 10/15/2001 4:55:17 PM Mountain Daylight Time, 
email @ redacted writes:

> My 22y/o daughter,Kara, was working w/Animas to get a
>  pump,which we thought was happening by the end of
>  Oct.Today we found out her insurance co wouldn't cover
>  it
>  because she has only had the policy 6 months & her
>  diabetes was prexisting condition. <snip>
>  Does anyone know if there is any information/help
>  w/this type of situation?
>  Animas said if her insurance co.wasn't self funded,we
>  could appeal to the insurance commission,but after
>  calling the co.found they are self funded.
>  Kara was dx 14 yrs.ago & has so many problems
>  contolling her bgs.She's been hospitalized w/dka &
>  least 12 times in past 3 yrs.

I can several tacks that you could take on this issue . . . 

First of all, I'm pretty sure that even self-funded insurance programs are 
regulated by some government agency (i would start by asking the state 
insurance commissioner, and NOT the insurance company since they're unlikely 
to volunteer any information that they're not required to).  This would give 
somebody for your appeal to outside of the insurance company itself.

Second, if it a plan that is self-funded by her employer, you might want to 
check with her boss and/or Human Resources Department on ways to appeal the 
decision THROUGH COMPANY CHANNELS rather than the insurance company, which  
the merely administers the plan according to the rules set forth by the 
company.  I've had friends who work in hospitals that self-insure their 
employee medical plan, and know that, if you can get to the right folks, it 
is possible to get exceptions made.

Third, I'd check on whether your state has laws on the books which require 
diabetes care supplies/equipment to be covered -- this *could* override the 
pre-existing conditions waiting period depending on exactly what the law is . 
. .

Fourth, I'd investigate the provisions of the plan to see if your daughter 
would be covered for any hospital admissions for DKA that might occur in the 
next six months (or if that's eliminated, too -- under the preexisting 
conditions clause) . . . because if hospital stays ARE covered, I would think 
that given the frequency that your daughter has gone into DKA, you could 
convince them that paying for the pump now could easily save them much more 
money than the cost of the pump. I think I read in one study that the average 
hospital stay for DKW costs $5,000 . . . 

Lastly, I'd ask the insurance company to at least give you advance approval 
for the pump, conditional upon your completion of the 6 month waiting period 
for pre-existing conditions . . . If you can get that, I'm sure you could 
work something out with Animas to enable you to get your pump sooner rather 
than later.

There are many ways to skin a cat -- just be creative and persistent . . . If 
you wear them down, they might just give in -- just to get rid of you . . . 
which made me think about one other idea -- maybe try contacting your local 
news stations as they usually have someone specializes as a consumer affairs 
reporter that will go to bat for the underdog ON CAMERA (and that can make 
things very uncomfortable for the "big bad" insurance company).

Hang in there!

Pumpmama to Katie
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