Rejected Medical Benefits Claim

[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.

[Slava]

Well in Alberta you could go through the Alberta Insurance Council and they handle complaints. Everyone doing business in Alberta is regulated by them. There is also an ombudsman called OLHI for the life and health insurance industry, which could be another avenue.

[Slava]

Forgot to mention, the company you’re dealing with might also have an ombudsman, and that’s an option as well.

[JonDuke]

Thanks Slava, the company does indeed have an in-house ombudsman and I'm not sure it they are the one that rejected my appeal. Also, OLHI is the 3rd party they suggest contacting. I know they are supposed to be impartial but was skeptical because they were suggested by the company that is rejecting my claim. I'll try them both.

[Northendzone]

Good rule of thumb on these bigger ticket items is to submit a pre-determination to the insurance company so you are not surprised when the claim is submitted.

you could try asking your doctor for a written letter as to why you need this bed as well, and then appeal to the company again.

[CorsiHockeyLeague]

I've never had to do this but for group health insurance, can an individual insured just straight up sue under the terms of the Policy? I'm wondering if you'd have to go through your employer, since you might not be a named insured on the policy itself.

[redforever]

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.

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.

[Ashartus]

Does your employer have a benefits consultant on contract that deals with these companies? I had an issue with my insurer (in my case they were rejecting an increase in my coverage because I admitted I had a sports-related knee injury many years before, and they felt that disqualified me from higher long term disability insurance), the consultant was able to get it sorted out.

[Buff]

This thread could be very handy.

I have type 2 diabetes and do a fairly good job of managing it but I have ups and downs and most of 2021 was a super hard year to get on track and stay there.

My A1C in November was 10.0.... yikes! My doctor prescribed me to get the FreeStyle Libre sensors. The pharmacy informs me that my plan doesn't cover them, I'll have to pay in full. Well, both my wife and I have generous health spending accounts, we can claim the sensors on those because we are both allowed to claim un-covered medicine or even the remainder of medicines that aren't fully covered. Nope. Not with the FreeStyle Libre sensors. I have to be insulin dependent to get anything back for these.

This is really terrible because the sensors have been a great tool for me to keep on track. So much easier to check my glucose levels by scanning the sensor at any point of the day no matter where I am. Way easier and better than finger pricking. I had given up on finger pricking because it takes time and effort and it just sucks. 3 months after my 10.0 A1C result my A1C was down to 5.8. But I couldn't afford to pay $100 per sensor. These sensors only work for 2 weeks. My recent A1C saw me back to 7.4, which isn't terrible but I can keep it close to 6.0 if I had the sensors.

The sensors are a great tool for diabetics to keep healthy. I really was able to learn how my glucose changes with certain foods. All these years I thought oatmeal was good for me, but it spikes my levels. Why didn't I know that before? Because I would normally check before meals and sometimes immediately after a meal. Rarely, if ever, would I check mid day or halfway between meals. Some foods don't immediately affect me glucose levels but will after an hour or two. Finger poking isn't convenient to learn this information. The FreeStyle Libre sensors give this flexibility and information.

I want to know how I can advocate for insurance companies to cover these sensors for any diabetic, not just those who depend on insulin. Or at least let me claim in on my health spending account. I can claim a bicycle but not a glucose monitor? My wife can claim a non-prescribed pedicure but not a doctor prescribed glucose monitor?

I have no clue where to start. The person in charge of benefits at my place of employment has not been able to help me.

[ken0042]

Buff, you may need to beat them at their own game. Can you ask your doctor to prescribe you insulin? Even if you are managing it with oral meds, they might be willing. Then now that you are on a more expensive type of prescription, it would be covered.

I never actually had my doctor or endocrinologist be willing to tell me that I was actually diabetic; however they both wanted me to go onto injectable insulin.
(That was before I did get my A1C back down to normal.)

[photon]

To me the question would be how does an insurance provider decide if medication a or treatment b or item c is efficacious for a given condition and is a reasonable item to pay out.

Do they make all those decision in house? Like have a team of people that read the latest studies and update the relationships and such? Or maybe there's a 3rd party provider that provides a database of such information? How often do they get updated?

[Shazam]

Originally Posted by photon

To me the question would be how does an insurance provider decide if medication a or treatment b or item c is efficacious for a given condition and is a reasonable item to pay out.

Do they make all those decision in house? Like have a team of people that read the latest studies and update the relationships and such? Or maybe there's a 3rd party provider that provides a database of such information? How often do they get updated?

It works mostly like this:

"Is it expensive?" -> Yes -> "Deny."

[Northendzone]

Originally Posted by photon

To me the question would be how does an insurance provider decide if medication a or treatment b or item c is efficacious for a given condition and is a reasonable item to pay out.

Do they make all those decision in house? Like have a team of people that read the latest studies and update the relationships and such? Or maybe there's a 3rd party provider that provides a database of such information? How often do they get updated?

they usually have some trained medical and dental professionals on staff, and then likely have arrangements with medical consultants

as a rule of thumb, they generally provide coverage for the least cost alternative

[Sr. Mints]

I had to contact the ombudsman at Sunlife after an obvious screw up on their part. And while I figured it was a waste of my time after a dozen back and forths with their customer service, they actually--surprisingly!--reverse their decision

In my case I phoned to inquire whether a drug was covered (and I record calls these days for my own purposes) and was told yes, and that there was no maximum coverage annually. The drug was something like $1100 per month

Something like March or April rolls around and my drug coverage is maxed out for the year, because it turned out there was a maximum. I can't stress how much this would have absolutely screwed me, as I have a number of health problems that all seem to be very expensive to treat

When I contacted the ombudsman, I also CC'd every level of manager whose email I had obtained, and laid the whole story out and spoon-fed it for them. I never sent them the recording of the call (I'm not even sure how, it's like 300MB from my phone), but I did give them the dates and times and a word-for-word transcription, and I'm sure someone eventually dug it up and listened. It still ticks me off that I had to take it that far

[Northendzone]

^ so what happens in the new benefit year?

Drug plans with maximums for life sustaining drugs are poor plan design. Maximums make sense for fertility drugs, or smoking cessation.

[calf]

Originally Posted by Northendzone

^ so what happens in the new benefit year?

Drug plans with maximums for life sustaining drugs are poor plan design. Maximums make sense for fertility drugs, or smoking cessation.

Honestly, this is why pharmacare needs to be a thing, especially for life sustaining medicines like insulin. Sure it's more government spending now, but businesses won't be burdened by the cost of providing these benefits to their employees, people won't have to make hard budget choices, and the burden on the healthcare system that happens if people don't choose medicine as a result.

There should be some equity too. My kid is on some pretty expensive medications, but are super fortunate that it's effectively paid for by the government. It's not right that others don't have the same access to their needed medicines.



For the OP - another avenue could be if you have a connection in HR at your company like a benefits manager, they can make some calls as well to help overturn the decision.

[Sr. Mints]

Originally Posted by Northendzone

^ so what happens in the new benefit year?

Drug plans with maximums for life sustaining drugs are poor plan design. Maximums make sense for fertility drugs, or smoking cessation.

They reset my balance to zero for that year. As for the drug, the coverage didn't change going forward, so I stopped taking it. It wasn't life-sustaining, just a migraine drug (aimovig). I don't even know if it was working yet, and with the cost to find out, we tried other treatments.

[vegasbound]

Originally Posted by Sr. Mints

They reset my balance to zero for that year. As for the drug, the coverage didn't change going forward, so I stopped taking it. It wasn't life-sustaining, just a migraine drug (aimovig). I don't even know if it was working yet, and with the cost to find out, we tried other treatments.

I haven't even got AB Blue Cross to cover Aimovig so I'm surprised you got an insurance company to cover something.

[Sr. Mints]

Originally Posted by vegasbound

I haven't even got AB Blue Cross to cover Aimovig so I'm surprised you got an insurance company to cover something.

I forget the name of the program, but for the first ~2 months it wasn't covered at all, and so the drug company had a program where they paid for it until insurance providers began offering coverage. As I recall it's because the drug was so new? I'm not even sure who set that up, my doctor or the pharmacy (Bioscript, out of Edmonton for some reason.)

[JonDuke]

Update:
As suggested above, I had 2 doctors write supporting letters, advocating for why I needed the bed, and sent those letters with an appeal to my insurers ombudsman. The reply said that they would need 30 days to review the letters. I assumed, because they are employees of the company that rejected my claim, that they would find a way to side with their employer again and I would have to go to the provincial ombudsman.

2 weeks later, I was informed that they would reverse the rejection and are now approving my claim. It took 3 months after the initial purchase and lots of stress but I'm very happy to have them finally rule in my favor.

Thanks so much for the advice.