Insurance company whine/vent

weezie825 · February 2011

Readers Digest Version:

Dear Insurance Company:

Please get your act together! Don't tell me something different every time I call. And don't deny something for a bogus reason when you actually have a totally different but legitimate concern. Either cover it or don't, just please LET ME KNOW soon so I can make other arrangements.

Love, Frustrated Mommy

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Long version:

Before I took DD for her evaluation with Star Cranial I called the insurance company to verify the following:

1. that the orthotic device is a coverable expense - Yes, it is. If medically necessary

2. that star was a participating provider- yes, they are

3. if I needed a prior authorization- yes, we do.

Star Cranial has been wonderful. They have been worked with my PCP to get all of the stuff in order to submit to the insurance company 3 days after our evaluation appointment!

Well Friday afternoon they got a preliminary denial. The denial came with a page from the benefit manual that had 2 sections highlighted.

1. There is a $2500 yearly cap on durable medical equipment.

2. Braces to reshape limbs are specifically excluded from coverage.

WTF? We have not gotten ANY durable medical equipment at all, and certainly have not met the yearly cap as it is barely February. We are not requesting a brace to reshape a limb. AND, I specifically called and verified that the orthotic we needed was not excluded.

So, I called the insurance compnay. I have to say the CSR was extremely nice and very helpful. I explained the situation to her and she took the time to dig into what is going on and figure it out.

She determined that while some plans do exclude the "helmet" mine does NOT exclude it. Then she called the prior authorizations department and asked them what the problem was. Apparently they do not have enough information to determine medical necessity.

I just don't understand. Why deny it if what they really need is more information? The CSR told me that I need to have the clinician call the insurance company and request peer-to-peer medical review.

For the most part our insurance has been great. They paid ALL of DD's $15K+ NICU stay and out only out of pocket was the $500 co-pay for an inpateint hospital admission. ($100 per day, capped at $500).

But I am getting frustrated. I feel like I am getting jerked around. If they are going to deny it fine. But at least get your story straight and let me know the real reason why!

jcsntms06 · February 2011

Oh Maria I'm sorry your having to deal with this crap. I hate Insurance Companies. Instead of someone doing a little bit more work on their end they just start denying coverage. Or instead of sending letters letting you know what other information they need, they deny coverage.

I hope you get the coverage soon.