Sunday, January 13, 2013

Happy New Year, from your friendly health insurance provider

Thirteen days into the new year and already I've spent a disproportional amount of 2013 figuring out how to appeal my insurance provider's decision to deny coverage for the medication I've been taking for the past nine years.  I received a letter notifying me of their decision last week.  My stomach has been in knots ever since and I've been plagued by incessant dread.and a sense of impending doom. 

This is not just me being melodramatic.  There is a lot at stake here and the potential consequences for me are huge.  The medication will end up costing me about $325 a month if I can't convince the insurance to continue paying for it.  Yet not taking the medication isn't an option either, unless my doctor can come up with something that works just as well.  I don't hold out a lot of hope for that though; we tried probably five different medications before trying the medication I take now.  None of the other ones worked.  

So I find myself in a situation that seems hopeless to me.  It appears that the only way to prevent a significant setback in my life - probably a financial one, since not taking medication would pose a serious risk to my health - is to convince the insurance company to pay for my medication.  I am, of course, going to focus all of my energy on building a persuasive argument.  My interactions thus far with the insurance company, however, have not been encouraging.  I spent the whole of last week trying to get information from them.  They say I should receive something in the mail, but I've yet to get anything.

Even my doctor seems to have abandoned me.  I called her office last Monday morning...and Tuesday and Wednesday and twice on Thursday...and nobody ever called me back, not even when I said it was urgent.  On Friday, I went to the office in person to find out what was going on.  There, the staff members at the front desk were extremely rude.  I was told that my doctor can't help me and that it's my responsibility to deal with the insurance company...As a [mental] health professional myself, I know that the doctor does, in fact, have if not a legal then an ethical obligation to help me with this situation.  The insurance company wants to know why the doctor considers my medication to be "medically necessary."  Obviously, the doctor is the best person to explain this.

I left my doctor's office on Friday feeling depressed and defeated.  I took the weekend off from worrying, but I'll be back at it again tomorrow.  I've scheduled an appointment with my doctor; it will no longer be possible for her to ignore me.  I had hoped she would be an advocate for me; I feel like I could really use one right about now.


  1. Do you have an insurance nurse case manager assigned to your case? The problem is that nowadays, it's the nurse case manager that spends time convincing insurance companies that treatments are medically necessary, not the physician. Perhaps one of these insurance case managers can get a hold of the doctor and have a dialogue to help you out.

    Such is the case with increasing medical costs. If a treatment is deemed not "medically necessary", it's cut out. Unfortunately, I don't see things getting better anytime soon.

  2. They tossed me out of speech therapy in less than a year with a serious brain injury that required me to learn to swallow before speech. I had to go use students at University for four more years for their training. They helped even spur me on to new ideas, like swimming to improve air flow while speaking. Yes, a case manager helps but they rarely assign one, unless it is a big disability. I still on the edge of just dropping my plan to use the premiums for maintenance and not filling their balance sheets, since I can't meet my deductible each year. The fear of death, keeps us paying them instead of using the money wisely.

  3. I'm so sorry that you're having to go through this. I understand the worries of not having coverage for NECESSARY medications.
    Might I suggest that you contact the pharmacutical company that makes the drug that you take. The medications I take are necessary for my survival, so the company that makes at least one of them has stated (and the hospital that gave me my transplant) if I ever can't afford the drug to call them and they will try to help me cover the cost. I don't know what kind of assistance they would be able to give, but I know the offer is there. Perhaps the maker of your drug would be willing to help reduce the cost for you as well.
    I would also recommend making a financial case to the insurance company. As in, what would happen if you didn't take this medication. What would the costs to them be if you had to be hospitalized or have some other medical procedure to fix what the lack of medication caused. I have made financial arguements to insurance companies and won an favorable decision that way before.
    I wish you the best of luck!

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  5. I agree with Alyssa. It would be best to ask for a medical certificate to prove that your medication is necessary for your treatment. Talk to your insurance company and explain that it is a part of your medical treatment. But if they refuse to heed your request, it may be best to look for a new insurance company that will address your needs.

    Keith Andrew

  6. I believe it’s a process for all insurance companies to have at least a medical certificate before they cover the process or operation you will undergo. Fair warning: not all health insurance companies have the same services. Some may give you an option of undergoing a lot of surgical treatments while others don’t. Choose wisely, and check if the insurance you’re getting will be beneficial for you in the long run.

    Elnora Cowge

  7. I hope you were able to work things out with your doctor. Health insurance does help in trying times, but at the same time, it could give you problems. I’m not saying that you shouldn’t get insurance. What I’m pointing out is that some people tend to overlook details regarding their policies that they are sometimes dumbfounded when everything comes to light. It’s important to be in the know-how especially if our health is in play.

    Hershel Duffey


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