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Re: [IP] Sorta OT but kinda relevant
> > You mean there's a chance your insurance co won't approve you for the
> PUMP or just the education along with the pump? . . .
> > Good luck. Tammy
> Yes my insurance company can deny me for the pump. And from what
> I have
> heard most any insurance company can deny a pump to a diabetic.
Respectfully, I disagree. If a doctor presescribes a pump and writes
a letter of medical necessity, the insurance company can not
contravene the doctors order .... that's called "practicing medicine"
by the insurance company and is specifically forbidden by law. The
insurance company can "claim" that certain criteria must be met or
that in goes against their "policy", but bluntly that's bulls..t
Unless there is specific language in YOUR COPY of the contract of
insurance that says that insulin pumps are not covered, then the pump
must be provided by the company. Since Insulin Pumpers began serving
the diabetes community, there has never been a case of a denied pump
(in the US) standing up in the face of a persistent person insisting
on receiving the benefits for which they contracted under their
policy of insurance.
You are right, many insurance companies are penny wise and pound
foolish about pumps. There is even a study a read last year that
showed medical costs for patients on pumps were almost half of
non-pump patients, primarily due to the decrease in OR visits. The
majority of insurance companies seem to have figured out the benefits
over the last few years, but their are still those that are dragging
their feet. Don't take NO for an answer.
> chance that if I get good control with the MDI (The proof will be in
> the A1c dropping) I will not get the pump because I have adequate
> control with a cheaper more conventional therapy.
heh... heh... that argument is a two edged sword.
Achieving better control simply indicates you would be an ideal
candidate for a pump because you do all the things necessary to
make pump therapy work well. Everyong knows that control improves on
a pump and that A1c's go down --- this pushes long term risk for
complications down yada yada yada.....
Likewise, should you have difficulty with control EVEN ON MDI, you
are a good candidate for a pump because with pump therapy make it
easier to achieve good control.
See.... depends on how you present the argument. And.... remember, it
is just an argument. The insurance company is OBLIGATED to provide
what the doctor orders absent specific contract language to the
contrary in YOUR COPY of the contract of insurance. You must hammer
home that point. Insist on seeing IN WRITING the language the says
they do not have to provide a pump. Yes, there are legal barriers to
suing your own insurance company for denial of service, but breach of
contract is not one of them and they know it. Also, the state
department of insurance would definetly have a few words to say to
any insurance company that denys medical services ordered by a
physician. For all insurance companies, there are standard appeals
procedures, usually two tiered. DEFINETLY get your denial in writing
and appeal IMMEDIATELY in writing (don't wait for the written refusal
to begin the appeal, but do insist on getting the document). Time is
of the essence with these things. Don't give them any extra time.
File appeals immediately, as soon as you can for each level. Be
persistent, and when and if denied at the final appeal level, file a
complaint with your state's insurance commissioner.
Bottom line --- it will not go as far as that. You will get approval
somewhere during the appeal process.
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