RE: [SPAM] Re: Insurance & Employer - Kristy

[Guest guest]

I think most of you remember the awful saga of my recent

denial of my surgery for my pudendal nerve compression and vestibulectomy. Thankfully

the day before my surgery, my insurance company decided to overturn their ruling

and would cover my claim. But this only happened because of the tenacity of a woman

in my doctors’ insurance office who would not give up and literally badgered

my insurance company with appeals and proof of claim.

And Kristy mentioned going to her insurance company first,

in my case my insurance company would not talk to me or my husband, under any

circumstances – only to my doctor. And my doctor took the time out of his

busy schedule to talk to the insurance company’s doctors.

In this case, we were desperate and went to the HR of my husband’s

company. He works for a large company whose main office is not in our state. He

talked to the head woman in HR at the corporate office that is in charge of

medical decisions (claims); we were told there was nothing that she (the

company) could do.

Fortunately, it did turn out fine for me, but I am wondering

if the size of the company (how many are employed) has any effect on how

medical claims are reviewed. Or are decisions made on a case by case basis. Everything

is supposedly stated in multiple pages of the insurance company’s employee

handout, but if the cases you mentioned can be overturned with a telephone call

– who really is in charge? There must be some kind of criteria for this –

whether it is a specific employer, insurance company, size of company, size of

insurance company or state. I can think of all kinds of variables – and if

this happened once to me, it could happen again. Does anyone have any thoughts

on this?

nne

From:

VulvarDisorders [mailto:VulvarDisorders ] On

Behalf Of Chelle

Sent: Tuesday, September 11, 2007 1:28 PM

To: VulvarDisorders

Subject: [sPAM] Re: Insurance & Employer - Kristy

Kristy Sokoloski wrote:

>>>>>>>>>>The employer has no

impact on what the insurance carrier decides

to put in their plan. I know this about the employer issue because with my

mom's if I have a complaint about something I have to go to the insurance

company first and then after so many times I can get them

involved to help with appealing. Kristy

Kristy, the Employer can have a say in what is

covered. I'll give you an example. When I was 8 months pregnant

with my first son, I found out the hospital I was to deliver at was not in my

Network anymore (changed on me during pregnancy)! As you can imagine, one

month before delivery...I flipped out...and cried my eyes out. My doc was

still in network...but like it really mattered if I was going to be stuck with

a huge hospital bill. My husband spoke with the head of Human Resources

at his Employer...she called the Insurance and told them to cover me as if that

hospital was still in Network! I also got my epidural paid for by calling

and making some 'noise' (determined, but in a polite way)..... *grin*

I had another situation as well, we called Human Resources

again, and they contacted the Insurance and told them to cover my birth control

pills. I was taking them for Endo and not for actual bc reasons....I

pointed out that I thought they should be covered when used for a medical

condition, and HR worked it out, they were covered!

Ladies, if your Insurance denies coverage on Compounded meds

or for other reasons, contact the Human Resources Dept. of your Employer and

get them involved, that is what they are there for. It may not work, but

it is definitely worth a try. It can potentially save you some

money!

Kristy, how is your mom doing? Are they giving her a

good prognosis about the breast cancer? Take care, ~Chelle