Insurance Appeals

[bmills]

Who has had success with insurance appeals after being denied ADR? Has anyone used the services of an attorney to handle the appeal? What have been the results?

Thanks.

Brady

[ESL]

I have had success with an appeal.....it took 1 year but it worked and i am scheduled to have a 2 level prodisc installation done in late April. The one thing that might be different for me is I work for a reasonably large company that is self-insured up to $100,000 per case....a committee of employees and managers make-up the appeal committee....I was able to prove to them that they will save money on me in the long run. I have been an employee of this firm for 15 years and that might have some bearing on their decision.

The one thing you guys can take away from this, is that many large employers (say over 500 or 1000 employees) have self retention levels that would make them essentially self-insured for a $50,000 ADR procedure. These companies all hire a 3 party administrator to serve as the "insurance company" and tap into a provider network like blue cross PPO. If this is the case for any of you, find out how to make the appeal to the internal appeals board rather than dealing with the insurance company directly (the 3rd Party Administrator or 3PA).

I hope this is helpful to somebody.