Quote:
Originally Posted by JonDuke
My medical benefits policy "provides payment for the purchase or rental of adjustable beds when prescribed by a physician."
My doctor prescribed and recommended I acquire an adjustable bed for GERD, so I bought one. The claim was rejected with no explanation as to why and it simply said "Expenses do not meet the terms and conditions of your policy"
So I emailed them back, asking for clarification, showing my documents and pleading my case. Via letter mail, they replied:
"Your policy speaks to "Benefits provided by this policy are available when deemed medically necessary by a physician or licensed health care professional." Chronic GERD is not deemed medically necessary for this product.
After this additional review of your recent claim by our claims manager our decision to deny your adjustable bed remains the same."
If my doctor prescribes something to me, how are they able to then say that it's not medically necessary?
Is an Ombudsman the next step and if so, what Ombudsman do I contact? Alberta because that is where I live?, The ombudsman in the province in which my insurance operates, or other? Their website suggests a 3rd party place to file a complaint but is that really where I want to go?
I would love advice on what my next step(s) should be.
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You really have to get your doctor to advocate for you. Something similar happened with my husband. Only after the doctor had sent in a third letter insisting that what he had prescribed for my husband was absolutely necessary did they finally relent and approve the expense.