[Patrick]

Originally posted by Leanne:
[qb] I am so sorry to hear about your insurance battle, but do not lose hope. I just "beat" Anthem in Kentucky. An independent review panel decided in my favor and now they have to cover my ADR, scheduled for 3/14.
I am an attorney, although I'm not licensed in your state so this is not legal advice per se. However, your case against them is in contract. Your policy is a contract. You fulfilled your duties by paying premiums, submitting claims properly, cooperating, etc. The company must fulfill its duties. However, you need to read your policy to determine exact what those duties are. Most policies are written in the affirmative -- "We will pay ..." -- with exceptions. I assume you are being denied based upon the "experimental/investigative" treatment exception. That exception is probably a defined term in the policy and you need to see whether your claim meets their definition. If not, and if there are no other applicable exceptions, your company must pay. "Will" is manadatory.
You need to request all documents and other data used in your appeal from the insurer. Find out exactly why you were denied and if that is correct. It sounds as if you have the burden of proof at this hearing, so you need to present evidence as to why the insurer is in breach of the contract (because your claim meets the definition of what is covered by the policy).
I'm emailing you my final submission to the external review board as well as their decision letter to me. I would submit your argument in writing like this prior to any hearing because it's hard to get everything in at hearing. I'd be happy to email this to anyone else in need of help. If someone has a contact at Dupuy Spine, I'd be happy to provide anything they want. Please feel free to contact me directly about this. I'm happy to help. [/qb]

Leanne,

I would also really appreciate an email of your final submissions. Thank you much