Reply To: Insurance Question

February 20, 2014 at 11:14 pm

I had a related issue with my insurance carrier (Anthem Blue Cross) where they denied coverage for my $18K power wheelchair. I went through all their internal appeal processes only to be denied coverage. I appealed to my State Department of Insurance here:

I filled a grievance against ABC for improper denial of coverage and requested an Independent Medical Review (IMR). This process actually took a shorter period of time (~2 months) than the 3-4 months I went back and forth with ABC just to get their denial multiple times. The State found that ABC had ignored proof of medical necessity and violated my rights. ABC was given the choice to pay for my wheelchair or a much larger fine from the State.

Although my situation didn’t specifically deal with a SNF, it could have. The point is that insurance companies like ABC and Aetna will bully us to get out of paying medically necessary bills. Maybe your State has an appeal process similar to that of California.

Medicaid may not provide the same level of benefits you may be able to get thru your State’s low income insurance programs. Please see my post here for more info about Medicaid and other options:

I had exhausted my 100 days of SNF coverage under my insurance plan before I came home. I did have to fight with my insurance several times when they wanted to send me home prematurely. I also fought with them over coverage for physical therapy in the SNF; they said I wasn’t progressing up to their standards. I discovered their standards do not include GBS and, because of my diagnosis of GBS at the time, I asked them to grant me additional time to show progress … they did after we sent them several certified letters appealing their prior decision.

I did not use an attorney to help me with my health care related battles. I went with an experienced private case manger/social worker. I found one (on Craig’s List) who was also a former Deputy Public Guardian with 25 years of case management and senior social worker experience. She helped me navigate all the red tape I was confronted with while I was helpless to respond myself due to paralysis.

There is a way to get around the income eligibility requirements of the low income health care programs. You would need an attorney to help you setup a special “trust” to shelter a portion of your income and secure your assets.

Your wife is lucky she has you to help her!