Insurance denied claim, HR says "benefit limitation", legitimate medical need (flat head) Who to contact now?

Question

Our son was born with torticollis (head severely tilted to one side) which lead to plagiocephaly (head flattened on one side). We contacted insurance to see if they would cover a helmet (DOC-Band) for him. They denied it, saying it was a plan limitation...they will not cover any cosmetic items that reshape the head. So, my wife and I paid $2700 out of pocket for the helmet.

Now, he is 10 months old and has had more ear infections than we can count. His pediatrician noted that his head shape has reverted to being flat, and that may be contributing to the ear infections. She wrote a letter of medical necessity for another helmet, which the insurance company denied, repeating the plan limitation. The appeal also denied, and the appeals dept. suggested we contact my wife's benefits dept.

The benefits dept. said there is nothing they can do, but I cannot believe that. The doctor says medical necessity, it should be covered, end of story. Is there a watchdog group we can contact?

Answer 1

They should obviously pay for it because it clearly isn't needed for cosmetic reasons. We had to fight with our insurance company, and here in Missouri, we contacted the department in Jefferson City that governs the insurance companies. Find your state insurance office. You will most likely get it paid for then. These insurance agencies do not like to be turned in to their governing body and usually will do whatever to keep from getting in trouble. Good luck!

Answer 2

You have the right to appeal a decision by your insurance company. Call them and appeal the decision. Quite often th insurance company will have a multiple appeal process. If you push them they will probably cover the procedure.