Insurance

March 27, 2001

Hello Bill -

I have pacificare but maybe this may help you- There is a new law here in CA

and this may go for other states as well but I can only go with what is in my

state - but its called Mental health Parity

It means that health care coverage for certain " mental disorders " must be

equal to that of physical disorders. Meaning in general that all terms and

conditions of your regular insurance plan will apply to the mental healthy

parity plan-

Now this is the hard part because Apraxia is not a listed for treatment BUT -

you are intitled to the consultation with the Behavior health provider - You

may then be able to discuss with this Dr the problems you are having - I know

alot of parents saying that they have behavior problems with their child due

to the inability to communicate.

The list of covered mental illnesses are severe but autism and PDD is one of

them.

Another route you may want to take is the nuerological route -

That is what we are doing because this mental health thing only applies to

insurance contracts renewed in 2000 and ours was not renewed in 2000.

I have heard that getting neurological backing gets more therapies covered

because of it being classified as a neurological disorder which in many

aspects Apraxia is that - the brain cannot trigger the correct movement of

the mouth in order to say the word etc -

So if it's possible maybe consider changing things to a neurological aspect -

we got our refferal from our PED - I told him I was worried about my son's

speech issues and was granted the referral immediately though it took 2

months to get the appt.

Also contact memeber services of your insurance and ask about mental health

coverage and what is covered - you may be able to get a flexible dr to write

you the letter you need to the insurance.

Good Luck

Mom to:

April 15, 1994 Full Term -

Alec July 26, 1998 -2 lbs 14 oz

Born at 29 weeks due to Pregnancy Induced Hypertension - He has Sensory

integration dysfunction - Social & emotionally delays - Speech delays -

Currently attending a preschool therapy program 4 days per week for 3 hours

per day

Undiagnosed at this point -

Seeking DX April 20 when we see a nuerologist

March 27, 2001

Bill - maybe this link may help you some -

http://athealth.com/Practitioner/Newsletter/FPN_3_11.html

May 7, 2001

Hello,

The only " Law " that I have heard about is that children under 5 receive 20

visits of PT/OT/Speech for congenital related problems. You may want to call

your state insurance advocacy center. I know the number of the one for

Colorado if you are located here.

October 15, 2001

-

Congratulations. Everyone who has " fought " has been an inspiration.

-Lynette

Mom to Galen

StarBand 6/12/01 -

Kansas

October 15, 2001

:

WOW - a year later and they at last coughed up the much deserved

money for the band!! That's great news. All your fighting and hard

work paid off at last. It goes to show us all that persistance

usually pays off in the end. Insurance companies count on the

insured to just accept their denials & give up - you're proof that

the fight is well worth it! I'm so glad for you. Like my dad always

tells me " The squeaky wheel gets the grease! " .

Thanks for sharing - this gives other parents fighting with their

ins. companies hope!

Debbie Abby's mom 3/1/00 DOCgrad 6/22/01

MI

> One year ago today my son received his starband. He wore it for

four

> months and we were very pleased with the results. I haven't posted

in

> a long time because we've moved on. But, I have to post again with

a

> great story. Last week we received a letter from our insurance

> company that they have agreed to pay for my son's startband. Thats

> right almost an entire year later but I did it. I can not tell you

> how many phone calls and faxes I have been through. I have heard

> every excuse possible from them and my greivance was 'lost'

countless

> times. But, a thousand dollars and principal was at stake and I

> planned to fight all the way. I did a cartwheel when I received the

> letter. Can you beilive it!! So, anybody out there fighting this

> battle-keep going- it was worth every $1000 !!! Our insurance

company

> was Blue Cross Health Options HMO- we live near Orlando Florida.

> Thanks to everyone on this page for all your help and everyone

> starting this process-just think a year from now it will over-you

> child will never remember it and it WILL be worth it!!

October 15, 2001

,

Congratulations!! I totally understand that feeling and it is a GREAT one!! I

fought my insurance company for 6 months and when they finally coughed up the

$700 it felt so great! I will second your statement about sticking with it.

The stall tactics and the denials are sometimes just a way to try and get you

to go away so they will not be out any money. Stick to your guns folks and

document, document, document!!!!!

Marci

October 15, 2001

Congratulations I hope our claim goes so successfully.

-----Original Message-----From: ginadx@... [mailto:ginadx@...]Sent: Sunday, October 14, 2001 8:26 PMPlagiocephaly Subject: InsuranceOne year ago today my son received his starband. He wore it for four months and we were very pleased with the results. I haven't posted in a long time because we've moved on. But, I have to post again with a great story. Last week we received a letter from our insurance company that they have agreed to pay for my son's startband. Thats right almost an entire year later but I did it. I can not tell you how many phone calls and faxes I have been through. I have heard every excuse possible from them and my greivance was 'lost' countless times. But, a thousand dollars and principal was at stake and I planned to fight all the way. I did a cartwheel when I received the letter. Can you beilive it!! So, anybody out there fighting this battle-keep going- it was worth every $1000 !!! Our insurance company was Blue Cross Health Options HMO- we live near Orlando Florida. Thanks to everyone on this page for all your help and everyone starting this process-just think a year from now it will over-you child will never remember it and it WILL be worth it!! For more plagio info

October 16, 2001

, I am so happy to hear that your insurance finally came

through! Good for you for not giving up and making them pay! Thanks

for sharing!

Niki

Kaylie & Danny (STAR grads)

Phila., PA

> One year ago today my son received his starband. He wore it for

four

> months and we were very pleased with the results. I haven't posted

in

> a long time because we've moved on. But, I have to post again with

a

> great story. Last week we received a letter from our insurance

> company that they have agreed to pay for my son's startband. Thats

> right almost an entire year later but I did it. I can not tell you

> how many phone calls and faxes I have been through. I have heard

> every excuse possible from them and my greivance was 'lost'

countless

> times. But, a thousand dollars and principal was at stake and I

> planned to fight all the way. I did a cartwheel when I received the

> letter. Can you beilive it!! So, anybody out there fighting this

> battle-keep going- it was worth every $1000 !!! Our insurance

company

> was Blue Cross Health Options HMO- we live near Orlando Florida.

> Thanks to everyone on this page for all your help and everyone

> starting this process-just think a year from now it will over-you

> child will never remember it and it WILL be worth it!!

April 4, 2002

,

I went to an attorney during the height of my battle with the insurance co.

They told me that I did have a case, but that since my helmet only cost $700

it would not be worth the expense of trying to fight it in court. That atty

recommended filing a suit in small claims court which I would have done if

the External Review Board had not reversed the decision.

I know that there has been legal action against some companies, but I'm not

sure to what extent.

Marci (Mom to )

Oklahoma

April 5, 2002

,

You might want to check our archives. There was a group of UHC policyholders

in the group not that long ago that were talking about a class action suit.

If you go to the webpage and put United Healthcare in the archive search box

you might turn something up.

I agree it is a terrible thing these insurance companies are doing.

Fortunately my daughter's helmet only cost $700, but at the time my husband

and I were both out of work and if it were not for my mom we would have had

to sell something to get it! Insurance paid 2 months after FINISHED the

treatment, but at least they paid!

Good luck and let me know if I can assist in any way.

Marci (mom to )

Oklahoma

April 5, 2002

, You know I am in.

I do not have a good feeling about my face to face hearing next week.

The neurosurgeon we saw wrote in a letterto my PED that he thought

Jane's case was too mild for a band and recommended repositioning

only. thinks her case is moderate (16mm cranial vault and 6mm

fac assy)I think this letter will hurt me in the end! Even if they do

overturn the decision I still feel like sueing for having put me

through this..and I am being very Brokovich about this. I want

the injustice to stop for EVERYONE!!!!

Since our bands cost $3,000...it may be worth it to look into the

costs of suing..I was always under the impression that in a class

action..it costs you only a portion of the winnings but nothing if

you lose..but I am no expert.

I would like to start a list of all the United Healthcare members who

would be interested!

Thanks,

> ,

>

> I went to an attorney during the height of my battle with the

insurance co.

> They told me that I did have a case, but that since my helmet only

cost $700

> it would not be worth the expense of trying to fight it in court.

That atty

> recommended filing a suit in small claims court which I would have

done if

> the External Review Board had not reversed the decision.

>

> I know that there has been legal action against some companies, but

I'm not

> sure to what extent.

>

> Marci (Mom to )

> Oklahoma

July 16, 2003

, I was curious about your post when you mentioned not

getting your son tested for insurance purposes. I was always

under the impression that if you/child is continually insured

then insurance has to cover CMT. Do you know much about this? Thanks

Take care,

July 16, 2003

:

Thank you for explaining this. I think I am becoming an example of this

type of treatment. My ankle fusion and all the expenses it entailed cost

almost $50,000. Now, the insurance company is trying to deny my claim on

the bone stimulator the doctor ordered after he realized that the bones were

not fusing, the braces that he subsequently wrote a prescription for, and

even the wheelchair that I had to have post op. I just thought I had alot

of really inept people working against me. They(the insurance co.) keeps

coming up with things like the wrong billing code was used or that I didn't

get preauthorization - when in fact I know the nurse did, I was sitting

there when she called. They are basically just giving me the run around on

the bone stimulator which is a cost of over $4,000 and the braces took

forever to get approved. I had to go for almost three months wearing the

walking cast because they wouldn't approve the braces. I'm not sure what

finally changed their minds on the braces, but I am very thankful that it

worked out. Anyway, the interesting part of this story is that I never had

any problems with claims before the accident when they didn't know I have

CMT. I have always gone to the MDA for check ups and really (thankfully)

never had a need to see other specialist for it. So, now what, I can't get

a cold without having a problem with my insurance? Is there anyway to

combat this sort of treatment? Thanks for the insight.

July 17, 2003

Hi :

Yes, my son is covered under my corporate group insurance policy, and he has

a small whole life insurance policy....but some day it is very conceivable

that he will want his own life insurance, or disability insurance.

Especially if he has his own family some day. If we were to label him now

with CMT, getting his own insurance may be very difficult, or at least

" rated " .

Try getting life insurance once you have had angioplasty, or you have taken

an anti-depressant. Good luck. Try getting disability insurance once you

have a disease that can disable you. But, if you get insurance some day,

before you know for sure you have an illness, that is OK.

I suspect there may be some differences in the way insurance companies

operate, in different places...I can only talk about how things work here in

Canada. You have to be very knowledgeable and cautious. It is not that I

want to be fraudulant, but if we do not know for sure, we do not know.

Regards,

July 17, 2003

Hi :

Yes, there are several ways to combat this sort of treatment, and it will take

effort. This is true whether you are dealing with insurance companies, the

Social Security Administration, state or province bureaucrats, or functionaries

that do 'review and approvals' of any part of the health maintenance chain.

Here's a bit more explanation to help illustrate the situations and suggestions

to get more favorable results.

" Claim Denied " or " benefits denied " are often rubber-stamp responses to a basic

insurance premise: Most folks denied benefits will simply walk away. Most will

not contest. Insurance, like medical care, is rationed. Only the persistent will

prevail. I hope this is not news to you. It is a modus operandi of insurance

dispersal...and it is the operational mantle big insurance has thrust into the

medical care system in the form of " managed " (read: " rationed " care.)Why ration

care? It is very costly and to restrict and portion it out, drives it's value up

(as in stocks.) Governments like to emulate successful business (profit) models,

so in the US (and likely Canada, too), SSI and state benefits are also

undergoing constant " tests " of their solvency and profitability, often to the

expense of those who are ill, permanently disabled or who treat and care for

them.

1) So, always resubmit or contest. Document/photocopy/ and keep records of all

stuff pertaining to your claim. Be sure to always cc your State attorney general

- Dept. of Consumer Protection - Health Claims or Canadian province counterpart.

Insurance companies do not want to hassle with a serious claimant. They will

often reconsider and settle, or clear any 'delays " in granting benefits. Even if

you mail nothing to your State or Province office, go to their online websites

and collect names of folks you are listing as " attention-to " for your cover

letter included with your claim resubmittal. These web sites may also feature

complaint forms that can often be filled out online.

2)In matters of health care, try to think of yourself as an 'consumer/advocate.'

While it is a sad state that the those with serious health needs must go to bat

for themselves against big systems, the expectation is that we won't. So,

Surprise everyone! Whether we limp, roll, or send email while bed-ridden, we

each of us have a voice. In most states and provinces, advocacy organizations

abound. Contact one and get active. Not just for the current hassle, but for the

effectiveness you will learn for the rest of your life. You can learn to help

yourself and others in a way you may never have considered. To be disabled is

often characterized as tragic. As Gretchen so aptly exemplifies, it can also be

a catalyst to greater learning and self-empowerment.

In the event you might wonder why I'm so passionate about this: I work as a

foundation scholarship administrator and workplace chaplain for my " day job " and

am an advocate for hard-core homeless in the community in my outside hours. I

also have lifelong CMT-1a and 20 yrs. of multiple sclerosis. Lots of challenges,

sure. Motivated? You bet!

in Newington

-----Original Message-----

From: finley [mailto:juliexbi@...]

Sent: Wednesday, July 16, 2003 5:17 PM

Subject: Re: Insurance