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[IPn] How it all began, part 3



I left off in the story with Lily asking "Dad can we go to McDonalds 
and get an apple pie". That was a pivotal moment for me, because it 
made it crystal clear what freedom an insulin pump would give a 
child. I knew I had to do something but at the time I didn't have a 
clue what that might be. 

So..., to continue with the "nasty" part of the story (it has a happy
ending). 

MiniMed had shipped the pump, my daughter was wearing it and a month 
or so later I got a letter from Blue Shield denying payment with some 
B.S. about it not being covered. Well, I'm not that easily scared off 
so I appealed.  

For those of you that don't know the procedure it is as follows:

1) you make a formal appeal (expecting it to be denied)
2) you make a second appeal (maybe it will be approved, maybe not)

These two appeals are a requirement under state law after which you 
can complain to the insurance commissioner. (I didn't do that, but 
you can do it effectively now most of the time).

To be truthful, I don't remember the exact steps I took, but I know 
that my appeals were denied and that I started to climb up the chain 
of command to find someone to talk to at the insurance company. Each 
time pointing out to whoever I talked to that my policy said that 
Blue Shield would pay for what the doc prescribes, and each time 
being told that they did not pay for pumps for kids, even though the 
policy had no such exclusion. Bear in mind that at the time pumps had 
been approved for adults, but not specifically for children. Now, 
there is nothing stopping a doctor from prescribing a medication or 
device "off label" and there is nothing in "my contract of insurance" 
that prohibited that. I think Blue Shield expected to scare me off, 
or I would get tired of trying.

I had read my policy very carefully and there were several lines in 
the text about diabetes and the prescribing of "items" by a doctor. 
Specifically, it said that if the doctor prescribed something for 
diabetes, the insurance company would pay for it. Yes, there were 
sections about "exclusions", but they only talked about experimental 
treatments with respect a diagnosis such as diabetes. BS was trying 
to jam the pump into that category, however it was (and is) an 
approved device. 

So after 15 MONTHS of screwing around with them, one day I got 
irritated and looked up the name of the CEO in the documents filed by 
Blue Shield with the Security and Exchange Commission. I called his 
office and the phone was answered by his executive assistant. My 
message was as follows as closely as I can remember it. "If I do not 
immediately get a check to pay this claim, I will sue you for breech 
of contract. NOT denial of service, but breech of contract. Your 
policy clearly states that you will pay for FDA approved devices 
prescribed by a physician for the treatment of diabetes."  

For those of you that do not know, a suit for denial of service would 
be the typical suit brought by a disgruntled patient that didn't get 
their treatment paid for and disagreed with the ins. co. where they 
might very well be right. A suit for breech of contract is a 
different kettle of fish. Since a contract of insurance is offered to 
"you" (meaning you and me) without the benefit of being able to 
negotiate it's terms, if a term of the contract is violated by to 
person or company offering the contract, the courts have generally 
given the benefit of the doubt to the party that was forced to accept 
the terms. Since the contract said "they will pay for prescribed 
diabetes devices", that would be a suit that is very win-able. Since 
at the time there were only ~5,000 kids on pumps in the entire US and
"maybe" another 5,000 in Europe. The possibility of opening the flood
gates by losing a breech of contract suit was by my guess not a very 
appealing scenario to Blue Shield.

So, after the 15 months of haggling with them, the check arrived 5 
days after the phone call. As I recall it was around $5,000 and 
change. My mission at this point was to "spread the word". The folks 
at (then) Minimed started referring parents to me for assistance, 
this dove-tailed into the genesis of Insulin Pumpers.

FYI, 5 years after this "victory", the number of kids on pumps in the 
US had risen to ~50,000. That number came from the two gorillas in 
the field at the time, Minimed (by then Medtronic), and Disetronic 
(now Roche).

More tomorrow.

In the mean time, please support Insulin Pumpers with a contribution 
to our pledge drive. Raising money is difficult and a small 
contribution from you would help a lot.

A sustaining contribution of $5 or $10 a month would be amazing! 
If you can't afford a monthly pledge, please make a contribution of 
what you can afford, at least once a year.

AND !!! a $100 challenge is on the table from a Southern California 
member. They will match what you pledge until the challenge is 
fulfilled.

	http://www.insulin-pumpers.org/donate/
or
	http://www.insulin-pumpers.org.uk/donate/

To help in a big way with a donation of $100 or more, please 
challenge the other members to match your generosity here:

	http://www.insulin-pumpers.org/challenge/

Insulin Pumpers accepts, Visa, MasterCard, Discover, AMEX and most 
other credit and debit cards.

AND...Yes, Insulin Pumpers has joined the 21st century, we do accept 
crypto currency, Bitcoin, Ethereum, etc....

...and not to be outdone, we accept JUNK CARS running or not, we'll 
arrange to tow them away if necessary.

	http://www.insulin-pumpers.org/cars/

Whew!! that's a lot, but there's more... you can mail a check to:

	Insulin Pumpers
	558 Valley Way
	Milpitas, CA 95035

My best regards,

Michael Robinton
Executive Director
Insulin Pumpers
..

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