Why You Should Persist When Dealing With Insurance Companies on Claims: A True Story

The following is a true story of a mom’s persistence to work with an insurance company to pay a health insurance claim. While this mother went through a lot, the point is that if you know your facts, you can come to an agreement with an insurance company.  Hopefully, you won’t need to go through this much, however, it’s important to not give up.  Insurance companies are run by people which means that sometimes they make mistakes, remember that you’re dealing with people and try to understand the insurance company’s perspective so you can find a win/win.  Here’s the story:

At age seven, Jane was diagnosed with Type 1 Diabetes Sunday May 8, 2016. Jane had been complaining of a bellyache and was becoming increasingly lethargic. On Friday we scheduled an appointment with her pediatrician for the following Monday; however, by Sunday we couldn’t wait any longer and took Jane to Generic Urgent Care. We think Dr. Kildare knew what was wrong with Jane almost immediately after hearing her symptoms; of course we were clueless. Dr. Kildare ordered a finger prick and confirmed his suspicions… Jane was in an early state of a diabetic coma; she was officially DKA – diabetic ketoacidosis. Jane’s dad and I were torn to pieces; with tears rolling down our faces we took Jane to the Hospital where Jane was rushed to ICU where she would receive insulin and close monitoring. The next week was a whirlwind, we couldn’t leave the hospital because we needed to learn how to care for Jane and her new diagnosis; we required a crash course in diabetes. One of the first things we learned was the dangers of hypoglycemia; low blood sugar. The bottom line with hypoglycemia is that if too low, Jane could lose consciousness, requiring one of us to inject her with glucagon. The glucagon pen is a syringe full of a fasting acting hormone that increases your blood sugar while you await emergency responders. Bottom line, this is the kind of scenario that keeps every T1D parent up at all hours of the night checking your daughter’s blood glucose ensuring that she will wake up in the morning. Of course, in order to check Jane’s blood glucose (BG), this requires a finger prick. What if I told you there was an approved medical device that can monitor your blood glucose throughout the day and night, notifying you of highs and lows so you can take action; there is, it’s called a continuous blood glucose monitor (CGM).

After learning about the CGM, Jane’s doctors fully supported and recommended that we apply through our medical insurance for a CGM, which we did through Acme healthcare. We were quickly denied based solely on the fact that Jane wasn’t 8-years old. First of all, Jane was only a few months away from turning 8-years old, but that’s not the point, so only children 8-years and older are allowed for better diabetes management and for the chance of preventing hypoglycemia!? We appealed on the basis that Acme healthcare was violating federal law, as this was age discrimination and that CGM is FDA approved for pediatrics. We received a second denial letter denying our appeal, Doogie Howser MD of Acme Healthcare stated “She does not check her blood sugar four times per day. In addition, there is no evidence that she injects insulin four or more times per day. Therefore, since your daughter does not meet necessary criteria, the monitor is not covered.” This is not only false, but outrageous that a medical director wouldn’t know the requirements for caring for a pediatric T1D. Jane most certainly checks her blood glucose more than four times per day, as well as, has more than four injections per day, which is supported and confirmed by her doctor, Dr. Welby. Furthermore, Dr. Welby called on multiple occasions to conduct a peer-to-peer review, at which time she was told was deemed unnecessary. I sent my appeal to the Escalation Unit and requested a second level screening, which I was granted. I was able to speak to a board of doctors, some associated with Acme healthcare, and some were not. Acme healthcare also had a representative on the line, as I plead my case. I presented a summary logbook from Jane’s blood glucose monitor, which confirmed that Jane’s blood glucose is checked at a minimum of five times per day but on average seven times per day. I also presented a letter from Dr. Welby that discussed Jane’s diabetic medical plan, which confirmed that she injects insulin more than four times per day. I spoke to the board for less than 20-minutes. After we ended the call, I immediately received a call back from the review facilitator confirming that she had never done this before, but she wanted me to know I won and she personally was going to call Jane’s doctor and let her know.

The moral of this story is to never give up, never take no for an answer, never stop fighting for your T1D. Make your insurance carrier work for you, not the other way around.

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