posted
posted 24 January, 2006 10:12 AM -------------------------------------------------------------------------------- Hi,
I posted last week regarding the fact my insurance is not going to cover for our family to see Dr. C a LLMD. We have had no change in our insurance plan. Last year my husband and I were covered 100% to see him. I appealed and we got approval to see him. Then in Nov they gave me approval for my two children to see him..
Then after the new year they are stating they will not cover for us to see this doctor. Of course I called after the new year and got approval and we went to see Dr. c all four of us and now they are saying they will not cover that visit or any others. So of course I am arguing this.
Now they are stating that antibiotics are expeirmental. When has treating a bacterial infection with antibiotics experimental?? So What I need is information to support the fact treatment with antibiotics is NOT experimental!
I figured some of you have gone through this very same thing so I need all the help I can get! IT shouldnt be this hard to get covered for LYME disease!! This disease needs to be more well know to others!
So my argument is that they have already started to cover for me and my husband 100% and how can they stop midstream after already covering. That would be like stopping treatments midstream if you have cancer.. Crazy they shouldnt be able to do that..
They have been covering 100% for me since May 2005, and for my husband July 2005. And there has been no change in our plan! I think they should continue to cover for us and our two children!!
So there reasons for not covering now is that antibiotics are experimental. That Dr. C treatment is experimental?!?!?!? I will not let this go without a fight.
If anyone has information that I could use to support coverage to see this doctor please send this way.
I am doing much better but my children and husband are having some problems. And they really need to see him. With all four of us seeing him.. The visits can be quite costly.
I just feel that they have covered they cant just drop us just like that!
We got approval from them and They should have to hold to there word!!
mlkeen
Frequent Contributor (1K+ posts)
Member # 1260
posted
It is frustrating to have coverage denied. We pay our doc out of pocket but our drugs are covered.
There are conditions in which long term abx use is accepted by insurance companied.
Acne is one. It is always listed as our diagnosis. Other things are listed from time to time as meds need to change. It seems so strange, but these are the rules so we get treated for acne. We have great skin!
I don't mean to make light of our plight. I just didn't have the energy to fight so we worked within the rules.
timaca
Frequent Contributor (1K+ posts)
Member # 6911
posted
see my post in general support about insurance appeals. I included a letter there that went to my insurance company. They used that line too "experimental". NOT.
LymeTimes has an insurance issue that is also very helpful.
-------------------- 5dana8 Posts: 4432 | From some where over the rainbow | Registered: Sep 2005
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luvs2ride
Frequent Contributor (1K+ posts)
Member # 8090
posted
Each state has an Insurance Commissioners office and within this office is a consumer division that is there specifically to help you.
Call them and ask them how to handle this. They are working for you and will be glad to guide you in this matter. They can advise you of any rights you may have and it won't cost you a dime.
I have 25 yrs in the insurance field, not in health insurance but in property and casualty.
Believe me, insurance companies quake in fear when they receive a complaint from the insurance commissioner's office. They always have to respond with a "good and valid" reason for their position.
I don't know if you have a valid complaint here or not, but the insurance dept will know and if you have the option, they will tell you how to file your complaint.
-------------------- When the Power of Love overcomes the Love of Power, there will be Peace. Posts: 3038 | From america | Registered: Oct 2005
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timaca
Frequent Contributor (1K+ posts)
Member # 6911
posted
It was my experience that the state insurance commission would not get involved until I exhausted all appeals with my insurance company.
Keep writing letters back to the insurance company. Send them FedEx so you know that they got signed for. Document that they got signed for (you can track it online). Keep copies of everything that you send to you insurance company.
7 out of 10 people give up and give in when the insurance company says that they won't pay. Then the insurance keeps their money. They are counting on you to give up and not write.
So, surprise them and write!
Posts: 2872 | From above 7,000 ft in a pine forest | Registered: Feb 2005
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I found this also.... truemanlaw.com The treatment is experimental. This is the approach that companies take whenever some treatment may not be commonplace. This is specifically the case in relation to approving treatment for bone marrow transplants for a variety of cancers.
Often the managed care contract will have specific exclusions for specific types of treatments. This is more easily done than calling a treatment not medically necessary and presents more of a problem for the patient. Generally, the terms of the contract will determine what benefits are available and if the contract lists specific treatments that are unavailable there may be little to be done even if an attorney is helping.....(i doubt that is your case~PinchotGail)
-------------------- Strength does not come from physical capacity. It comes from an indomitable will ~ Gandhi Posts: 562 | From Wellsville, PA, USA | Registered: Jan 2004
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posted
I had the same response from my insurance co. IV is experimental. This is really frustrating since I pay $850 a month for my son and me to be covered.
So I sent in an appeal and got another denial. I am going to PM the rest. Bottom line, I just paid $3700 for 1 month of Primaxin. Ouch. I will only do one month at this cost. They also denied Home Health in mid stream and I cannot drive for weekly blood draws and I had to hire someone to take me.
There are enough obstacles. If I were on MS meds it would cost the ins co. $1200 a month. Ironic.
Posts: 830 | From Colorado | Registered: Mar 2005
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timaca
Frequent Contributor (1K+ posts)
Member # 6911
posted
aliyalex~
At least with my insurance company...you could have an independent person look at your appeal...once the company thoroughly denied you. Just because they denied you a second time, doesn't mean you are out for good. I would keep at it....at least if you want them to pay.
Check your policy...or with your insurance company...
Posts: 2872 | From above 7,000 ft in a pine forest | Registered: Feb 2005
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luvs2ride
Frequent Contributor (1K+ posts)
Member # 8090
posted
timaca
Every state has different laws governing insurance.
BBWagoner
Check with your insurance commissioners office to see what options you have.
-------------------- When the Power of Love overcomes the Love of Power, there will be Peace. Posts: 3038 | From america | Registered: Oct 2005
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JimBoB
Unregistered
posted
BBWagoner: EVERY treatment for Lyme IS experimental. IT HAS to be for the insurance companies.
THEY have seen the handwriting on the wall, and KNOW what kinds of BILLIONS of dollars this is going to cost them in the future, IF and once it is considered "normal" and mainstream to treat Lyme.
We MUST remember, LYME is in epidemic proportions already.
We ALSO must remember, that SOMEBODY has to PAY the insurance companies. GUESS who is elected to do so in actually. US of course. Even IF our employers do so, WE are still the ones doing it, because IF they did not have to pay OUR insurance, they could pay US more for a decent wage, or better wage.
We must also remember, that the insurace companies are in it for one reason, and one reason ONLY; and that is to make as MUCH MONEY AS POSSIBLE. Period. And the LESS they pay US, the MORE for their pockets. Correct?
THEY are run a lot like our government, only have learned HOW to make money better.
I had to bite the bullet and sell of some of my possessions here as I have NO insurance. BUT I also have to exclude the super expensive newer abx. However the way I have come up with getting around faster cures with the expensive abx is to use many, good herbs along with more common abx. Keeping the abx to a minimum also should help from screwing up my personal "ecosystem" quite as bad.
AND we need to build up our immune system for future needs.
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