Insurance Claim Frustration
Struggling to appeal a denied insurance claim for mental health coverage
January 2013 — I am presently reading a biography on Harry S. Truman (33rd U.S. President). I have discovered that he was a colorful character who was known for his "Giving Hell, Harry!" speeches, for ending World War II by authorizing the dropping of the atomic bomb on Japan, for his expressive sayings like "he doesn't know horse shit from apple butter," and for his desire "to do the right thing."
While engrossed in this book and reading about President Truman's challenges, life goes on and I have been involved in my own challenges — like dealing with my wife's employer's health insurance company. A few months ago I filed a claim to cover my counseling for depression, a condition associated with diabetes. It was quickly denied because they "didn't recognize the code" on my claim form. My wife, the primary on our plan, attempted to find out just what code would satisfy them, since no other explanation came. I mean, I could supply other codes, like my debit card code, voicemail code, or my wireless router code, but they wanted something more medical oriented.
In any event, my calm and reasonable wife, Tanya, attempted to access this information by telephone. Now, Tanya is a formidable opponent. When it comes to patience, she has tons of it and could bring Job to tears. Her call was promptly received by a machine that put her on hold. When a human voice did come on the line (after a several minutes) Tanya was told that she did not handle these types of claims and promptly put her back on hold. Tanya then began looking through a magazine. Thirty + minutes later, Tanya decided to hang up and address this issue with her human resources department, who eventually was able to establish communication with the insurance company.
We learned, again, that our carrier did not recognize the code (provided by my counselor) on my claim form, thus they disputed that my condition was covered under the plan. I contacted my counselor and asked if another code could be used to describe my condition. She confirmed there was one, quickly supplied it, and it was just as quickly denied. This time the insurance company reported they were being "good stewards" of the plan by denying my unqualified claim. I also received a scolding from them for soliciting an alternate code from my counselor. Evidently that was a big "no-no" in their "denying claims is business as usual" world. By this time, I was thinking that they didn't know horse shit from apple butter.
The recent outbreaks of gun violence and people being pushed in front of subway cars has brought the issue of mental health to the public's attention. I have to question if the perpetrators had been denied coverage for their mental health conditions or received proper treatment. Maybe their health insurers, like mine, are insulated from their life and death decisions as they proudly pursue their mission of "good stewardship."
With our mental health crisis now showing up in our neighbors, co-workers, schools, etc., I am thankful that I am not employed in the health insurance claims field. If I was, I would probably lie about my profession and say I was in human trafficking, dog fighting promotion, or suicide bomber recruiting. I definitely wouldn't want to be associated with an industry that denies health claims and prevents people from getting treatment for conditions that can not only harm the patient, but also those with whom they come in contact.
Let's be honest, the mental wellbeing of our people is critical to the health and safety of our society. Isn't it time that our political, business, and community leaders come to together to "do the right thing" and put people, not profit, first?
dLife's Viewpoints columnists are not all medical experts, but everyday people living with diabetes and sharing their personal experiences, most often at a set point in time. While their method of diabetes management may work for them, everyone is different. Please consult with your diabetes care team before acting on anything you read here to find out what will work best for you.
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As I mentioned in an earlier post, one of the benefits that made it cost-effective for me to go with the real healthcare (HSA) plan rather than the phony (HRA) plan is that my company is now covering "preventative" medicines at $0 copay. The formulary for these, as stated by CVS/Caremark (my pharmacy benefits provider), covers all test strips, lancets, and control solutions. I dutifully get my doctor to write up prescriptions for all of my testing needs, submit...