Dad's insurance won't pay for needed treatment...?

Question

I'll make this as brief as possible...my father has a blood condition; he is missing a chemical in his blood that is essential for his immune system. He receives shots or "infusions" once a month, this has increased in frequency since he was diagnosed well over 20 years ago.

The problem is, his insurance company will not approve/pay for the treatments any more than once per month. They are very expensive. His condition has advanced to the point where he NEEDS the infusions every 3 weeks, or he starts getting very sick and can't fight off any infections. He was recently hospitalized as a result of one of these episodes. His doctors (three of them) agree that he needs the treatment once every 3 weeks. I am a graduating law student taking the bar exam in July. What can I do/what is the best method for ensuring he can get the treatment he needs? He is in California, where I will be also, he has good insurance, is 68 and otherwise in good health. ANY advice is greatly appreciated.

Answer 1

See if you can appeal to have them paid as a medical necessity. Have you checked to see if Medicare will pay for this as often as he needs? Is he currently only under your moms policy or does he have his own as well?

If the poilcy is an ASO (meaning if the policy is thru a large company like verizon, target etc) Then the employer actually pays their own claims and therefore make their own rules and the insurance company simply administers the policy and pays the claims using the employers own money. If its a group like this you may be able to appeal directly thru HR.

(Did you hear about the brain damaged lady recently that walmart was suing for like $400k? Its because they are an ASO and technically paid it themselves.. and in the end it was their decision to let her keep the money).

For an appeal there is a process that needs to be followed. You appeal to the insurance with all the info you have.  It may take a few steps to get to the top of the food chain there; then you can request it be sent to an independent review board. If they deny it too, then you can appeal to the DOI (Dept of Ins) in your state but you have to do the legwork first, you cant just go right to the State.

Also, see if the shot itself can be paid for under his drug plan and not major medical. Then you'd only have to pay for the actually admin of the shot thru the medical coverage.

Answer 2

If his policy specifies that infusion is only covered for 1 treatment per week (or 12 per year), then he must either (a) pay for 5 treatments per year and have the insurance pay for the other 12, or (b) find other insurance.

If the policy does not explicitly limit the number of treatments that are covered, but the insurance company is claiming that the treatments are not medically necessary, then take these steps (in this order):

1. The insurance company's appeal process

2. The IMR (Independent medical review) process

3. Involve the state government

4. Binding arbitration

Most health insurance policies in CA now require binding arbitration rather than suing.  Even if the policy does not specify, arbitration is less expensive than a lawsuit (except in small claims court), especially when either party is an insurance company.

Answer 3

Can he do his own infusions? That might be cheaper than going in to have them done.

My cousins get infusions at home for hemophilia because they may not have time to make it to the hospital.

Answer 4

If he is 68, he should be enrolled in Medicare.  What are the coverage options there?

Answer 5

I'd talk to a lawyer.

Answer 6

Without a policy to review, it is impossible to give an exact answer.

That said, in general, most policies will provide an appeal clause. If the previous dosage use to be enough, but his condition has worsened, the company needs to understand that this is now a medical necessity. File an appeal using his doctor's report that the dosage needs to be increased.

The appeal might fail. Regardless of whether it is necessary or not, the company will only pay for what is covered under the policy conditions.

Good luck.

Answer 7

OK, you've left out the most important part - WHY is the insurance company refusing the additional treatments?  They have to give a reason when they deny coverage.  

If the reason complies with the policy terms and conditions, there's not much you can do.  If it doesn't, you need to appeal.  Even if it does, I'd appeal, or else you'll be paying out of pocket.  The way I see it, it's not EVERY treatmetn they're denying, right?  Only the ones that come more often than once every 30 days.  

Anyway.  You can also complain to your state insurance commissioner.   Keep a couple things in mind:  appeal requests and complaints MUST be in writing.  Obviously, keep a copy of the appeal request and complaint.  AND, an insurance policy is a CONTRACT.  You're only going to win the appeal/complaint, if they are in violation of your CONTRACT.  The contract has terms and conditions and LIMITATIONS.  I've never seen an insurance policy that "covers anything they need, no matter what".  Ever.

As an aspiring lawyer, you can probably appreciate what that means.