posted
Help! after 7 to 8 years of fighting more than one lyme infection, losing many many days of school and lots of other things a kid should enjoy, my then 14 yr old daughter was put on 2 mos on IV rocephrin followed by 3 mos of oral... she felt better for a time (as she has so often over the yrs. Sick a few mos, Better a few mos.)
so we thought we had a pre-cert for the treatment in LLMD office. we thought most of it would be paid for. After a year of back and forth and finally exhausting the internal claim, this is what we have been told:
"the internal phys consultant concluded there was insufficient evidence to substantiate a valid med need got IV (my abbreviations)
"..the duration of IV excessive and not in accordance with generally accepted med prac"
reviewers questioned: "diagnosis"
our MD is one of the authors of ILADS guidelines.
we think we would like to fight this -- a suit under ERISA --
any ideas? any experience? we have 45 days to do this!!!!
We know many of you are paying out of pocket for similar reasons but wouldn't it be nice if we could find ways to fight this sort of thing????
-------------------- mom & co. Posts: 31 | From ny | Registered: Feb 2006
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trails
Frequent Contributor (1K+ posts)
Member # 1620
posted
The insurance is not a self funded plan, and is guided by ERISA?
I am not familiar with ERISA rules and fights. And I am not familiar with NY laws. Hopefully someone who knows these things will come along.
Is it at all possible to hire a lawyer? I would say your best use of time right now would be doing the following: 1)copying and organizing all the notes that relate to the case. 2) finding the leader of nearest support group or a support group in NY who might know the laws and have other good info for you 3) researching the Lyme or med laws in NY 4) researching insurance appeals with ERISA 5) finding a good lawyer
I think you can win this. I am winning a case right now where I had out-of-network surgery and 8 months later ---they are saying they are going to pay for it as if it was IN-network. (the check has not been sent so please send prayers)
I called almost every day. I was the squeekiest wheel ever. I squeeked and squeeked. I wrote letters, and faxes and called and left messages.
Eventually my file became so large they lost half of it and they couldnt process it correctly. Now the deputy director of the insuarnce authority (would be like ERISA is to you) has been calling ME for 2 weeks trying to get it all worked out.
She is my angel.
I think if you can claw your way to the top there are good people up there. It is the front people who have NO POWER that get in your way and make things impossible.
Good luck to you!
Can anyone else help?
Posts: 1950 | From New Mexico | Registered: Sep 2001
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posted
Did you do a search of the archives of lymenet? Try search word insurance. Many people have had this problem, some have won. Not sure the ins and outs on ERISA. CALDA has a special ins issue. Can google them and get a copy of this, think there is a charge, but worth it.
Posts: 8430 | From Not available | Registered: Oct 2000
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posted
Hi gang -- have done all that you say (before this).
ERISA are federal laws that limit a law suit against self-insured plans, meaning those financed by an employer or union. These do not come under state laws. Only federal. The Insurer can only be help liable for the cost of the payments -- nothing more. I have been told, the inurer will fight with big guns to win even when the amount is small. If they win, I will not only loose the cost but also the cost of the legal fees. In this instance i will back out. I am trying to inform the entire UNION board and others about the Lyme issue. I have multi-copies of Lyme Times about kids and about insurance which are being past around.
each of us needs to fight some how...
-------------------- mom & co. Posts: 31 | From ny | Registered: Feb 2006
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bettyg
Unregistered
posted
breaking this up for us neuro lymies to read...
Jons, please hit the ENTER key often and double space please; thanks.
Sorry to read about the outcome. Yes, we have all got to fight our battles & when to quit.
quote:Originally posted by jons:
Hi gang -- have done all that you say (before this).
ERISA are federal laws that limit a law suit against self-insured plans, meaning those financed by an employer or union.
These do not come under state laws. Only federal .
The Insurer can only be help liable for the cost of the payments -- nothing more. I have been told, the insurer will fight with big guns to win even when the amount is small.
If they win, I will not only loose the cost but also the cost of the legal fees.
In this instance i will back out. I am trying to inform the entire UNION board and others about the Lyme issue. I have multi-copies of Lyme Times about kids and about insurance which are being past around.
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