Sooner
04-12-2009, 11:44 PM
I just found out last week that my husband's company approved my disc replacement with a Prestige Cervical Disc. I am scheduled to undergo an ADR at C5-C6 on 4/14. My husband purchased Laurie Todd's book "The Insurance Warrior" and wrote a blockbuster appeal using her methods. It was well worth the $18. He cc'd copies to Empire BCBS, his company's HR department, and his brother-in-law who is an attorney for the 2nd level appeal. We're not sure if Empire even bothered to read the 80 page appeal but it must have impressed someone in his company's HR department because they overrode Empire's 2nd denial and agreed to cover it as "in network".
His company's plan is self-funded so they have the final say on coverage. My husband was optimistic that the HR department would side with us and he was right! My advice to anyone who is fighting this battle with their insurer that before you write your appeal, purchase Laurie Todd's book and use her methods. This process has really opened our eyes to how health insurance plans really work when you have a potentially expensive health problem such as disc replacement or, God help you, cancer.
The good news about self-funded group plans is that your employer pays for your health care and have the final say on what they will pay for. The bad news is that these types of plans are covered by a federal law (ERISA) and your only recourse is to file a complaint with the Department of Labor to force your employer to pay for treatment. You cannot sue for punitive or monetary damages. The only thing you can win is your treatment. But what good is this to anyone if you are dead? Because of this, most attorneys won't even want to take your case because there is no money in it for them. The system is stacked in favor of the insurer and the employer and therefore they have no incentive to pay for treatment if they don't want to. You are literally at the mercy of your employer to do the right thing and pay for your treatment. There are instances where the employer finally approves your treatment but by that time it may be too late to do any good (i.e. cancer). Thank God my husband's employer agreed to do the right thing and pay for my treatment.
Group or individual plans that are not self-funded are not covered by ERISA and you do have more legal recourse if the insurance company doesn't want to play fair. You can sue for damages and file a complaint with your state insurance commissioner. The bad news is your employer has little or no influence with the insurer to convince them to pay for your treatment since it is the insurance company who is paying for your treatment.
The main point I want to make is that you or a family member need to be the the one in control of the entire appeal process. You must be polite, proactive and assertive if you want the best care possible! Don't just assume that your surgeon or his staff will do it for you. If your surgeon, doctor, lawyer is any good then they will be too busy to do it all for you.
Good luck to all who are still fighting this process. At times over the last six weeks I felt like giving up and agreeing to have a fusion just to get it over with. I'm really glad I hung tough and saw it through to the end!
Please keep me in your thoughts and prayers over the next few weeks. I will try to post again soon with an update on how everything went.
His company's plan is self-funded so they have the final say on coverage. My husband was optimistic that the HR department would side with us and he was right! My advice to anyone who is fighting this battle with their insurer that before you write your appeal, purchase Laurie Todd's book and use her methods. This process has really opened our eyes to how health insurance plans really work when you have a potentially expensive health problem such as disc replacement or, God help you, cancer.
The good news about self-funded group plans is that your employer pays for your health care and have the final say on what they will pay for. The bad news is that these types of plans are covered by a federal law (ERISA) and your only recourse is to file a complaint with the Department of Labor to force your employer to pay for treatment. You cannot sue for punitive or monetary damages. The only thing you can win is your treatment. But what good is this to anyone if you are dead? Because of this, most attorneys won't even want to take your case because there is no money in it for them. The system is stacked in favor of the insurer and the employer and therefore they have no incentive to pay for treatment if they don't want to. You are literally at the mercy of your employer to do the right thing and pay for your treatment. There are instances where the employer finally approves your treatment but by that time it may be too late to do any good (i.e. cancer). Thank God my husband's employer agreed to do the right thing and pay for my treatment.
Group or individual plans that are not self-funded are not covered by ERISA and you do have more legal recourse if the insurance company doesn't want to play fair. You can sue for damages and file a complaint with your state insurance commissioner. The bad news is your employer has little or no influence with the insurer to convince them to pay for your treatment since it is the insurance company who is paying for your treatment.
The main point I want to make is that you or a family member need to be the the one in control of the entire appeal process. You must be polite, proactive and assertive if you want the best care possible! Don't just assume that your surgeon or his staff will do it for you. If your surgeon, doctor, lawyer is any good then they will be too busy to do it all for you.
Good luck to all who are still fighting this process. At times over the last six weeks I felt like giving up and agreeing to have a fusion just to get it over with. I'm really glad I hung tough and saw it through to the end!
Please keep me in your thoughts and prayers over the next few weeks. I will try to post again soon with an update on how everything went.