How do you sue your health insurance company?

[Experimental]

I am insured through a self-funded insurance through work. The plan itself is administered by Wells Fargo. Recently I was told over the phone by a rep from Wells Fargo 2 months ago that a CGM was covered 100%. I ordered it per my doctor’s recommendation, and when the claim was submitted it was denied. I appealed the decision and an independent party agreed with the initial ruling and the final decision was a denial. I am now left holding the bag for approx $3,000 and have been told the next step if to take legal action against the health insurance company. What type of lawyer should I be looking for. IE civil, personal injury, ect
OH by the way even after sending them all the studies and articles about the CGM they deemed it to be experimental and investigational.
:confused:

[JediSkipdogg]

You would need a civil attorney that specializes in going against large corporations. I will say....I hope you have lots of money because the insurance company can drag you out to no end. That's one reason I won't do anything expensive without my insurance approving it in writing. Therefore they can't deny they agreed to it.

Will the company you chose to get a CGM from not take it back? And what CGM and supplies did you get to rack up $3000?

[moorejames]

Check with your state department of insurance and see if they have a dispute resolution procedure in place for self-funded insurance plans.

Likely, they will still have some jurisdiction over things. Though the independent party probably *was* the dispute resolution proceeding.

The other option is to file an "errors and omissions" claim against Wells Fargo's E&O insurance. You'd probably have to file suit in order to do that, but since it's under $5k, you might be able to do that in small claims court and save the attorney fees. If they get sued over this, their Errors and Omissions insurance is the policy that would respond.

Having documentation of the Wells Fargo employee telling you that will be crucial though. Otherwise it's just your word against theirs.

[Experimental]

I got the MM Paradigm Real Time System which the starter kit came to approx $800 and then they shipped an additional 2 months of sensors which total cost came to $2000. These are the costs before the pre-negotiated insurance pricing kicks in. My infusion sets would be $1000 a month but after the negotiated price they drop to around $200. My plan covers all durable goods at 100%. Unfortunately they inform me that the CGM is investigative and experimental.

[Experimental]

Having documentation of the Wells Fargo employee telling you that will be crucial though. Otherwise it's just your word against theirs.

Wells Fargo informed me that a statement of benefits over the phone does not guarantee coverage.

Since I have no limitations on regular glucose finger tests I am now testing once an hour and with each test strip costing approx $1.00 I am hopeing that they will soon see the monster they have created.

[Alice]

It takes a lot of money to sue...I have a high school friend who specializes in health insurance law...he sues big companies. He's with a huge firm in Manhatten.

[Experimental]

The only major problem I forsee with a lawsuit is that Wells Fargo only administers my plan. We are self-funded through my company so if there is a suit it will be brought against my employer not the health insurance company.

[Alice]

There should be a mediator available at your company. Often, it's a third party to remain neutral.

[Experimental]

They are in the process of seeing if my company will pay for it directly out of their own pocket. I am going to bring the Americans With Disabilities Act to their attention.

"An employer is required to make an accommodation to the known disability of a qualified applicant or employee if it would not impose an "undue hardship" on the operation of the employer's business. Undue hardship is defined as an action requiring significant difficulty or expense when considered in light of factors such as an employer's size, financial resources and the nature and structure of its operation."

[JediSkipdogg]

The ADA has NOTHING to do with what health insurance must cover, so not sure why you would even bother bringing that in.

[Experimental]

I bring that in because a wheelchair does not make a person walk again yet it's covered and not considered experimental. When I have low or high glucose levels thinking can become clouded. I work in the Auto Insurance field and if I am making advise to someone in regards to their policy and judgement is clouded then i could lose my job. Being SELF FUNDED my company pays all the claims themselves yet they are paying someone to administer the plan on their behalf.

[Experimental]

The ADA has NOTHING to do with what health insurance must cover, so not sure why you would even bother bringing that in.

Being in Ohio I would hope you look at the Ohio revised code listing Diabetes as a condition that can be covered under workmans comp.

[JediSkipdogg]

But a wheelchair does not fall into the ADA. A ramp to get that wheelchair into the business/employment would.

The CGM would have nothing to do with the ADA. Giving you a reasonable amount of time that does not cause undue hardship to your work to correct when the CGM gives you a high/low reading would be ADA material.

[JediSkipdogg]

Being in Ohio I would hope you look at the Ohio revised code listing Diabetes as a condition that can be covered under workmans comp.

And I would hope that you would look at the section that says Diabetes supplies are not mandated to be covered by insurance in Ohio. Ohio is one of a handful of states that insurance is not forced to cover diabetic items, they do it as a courtesy.

Again though, a CGM has nothing to do with workmans comp.

[Funnygrl]

My infusion sets would be $1000 a month

WHAT!?!?!?!?!?!? Where the heck are you getting your sets from?

[Experimental]

Sorry about that what I was meaning to say was that wheelchairs are covered under my health insurance yet they only serve as an aid to a condition not a cure for it.

[Experimental]

WHAT!?!?!?!?!?!? Where the heck are you getting your sets from?

Edgepark medical supplies
4 boxes of Silhouette sets = 1056.48
I change the set every 1 to 2 days
pump reservoirs 314.60 for 4 boxes

[JediSkipdogg]

WHAT!?!?!?!?!?!? Where the heck are you getting your sets from?

I wondered that too and forgot to reply to it. At max, infusion sets should be $350 a month. The REGULAR price is $35 a set for 3 day wear. Then insurance works from that price down, but at this time I don't believe any have successfully gotten a lower price since they aren't buying a large enough quantity yet.

[JediSkipdogg]

Sorry about that what I was meaning to say was that wheelchairs are covered under my health insurance yet they only serve as an aid to a condition not a cure for it.

They serve as an aid for a person to get around and be able to live a normal life. Without a wheelchair the person would be homebound 24/7 without the assistance of another person.

A person with diabetes can still get around on their own without a CGM as diabetics have been doing it for tens of years with no problems. If the condition is so severe that you can't do that, then you obviously have numerous hospital logs from going there often, at which case that proof alone would most likely be enough for medical necessity.

[Experimental]

Wells Fargo says the CGM device itself, in their medical opinion is experimental and investigational and will not cover it. Even with my letter of medical necessity, numerous e-room visits and eye surgery already being preformed on both eyes.
Total of all those costs far exceeding the cost of a CGM

[Funnygrl]

Edgepark medical supplies
4 boxes of Silhouette sets = 1056.48
I change the set every 1 to 2 days
pump reservoirs 314.60 for 4 boxes
If you don't have insurance making you buy from there, they are by and large the worst place to order from. They WAY over charge. And why are you changing it daily?

[Funnygrl]

Edgepark medical supplies
4 boxes of Silhouette sets = 1056.48
I change the set every 1 to 2 days
pump reservoirs 314.60 for 4 boxes
Are you sure that's not meant to be a 3 month supply?

[Experimental]

I order from this company since my insurance at this time covers everything Diabetes related except the insulin as a durable good meaning I have no copay I do however get the bill sent to me before and after the provider discount.
The CGM is the first thing that I have ever had denied by this company. They are even paying for diasocks. Which are sold at $84.00 for a 6 pack before the provider discount.

I realize there prices to regular consumers is a rip but until the CGM not being approved EVERYTHING was covered with no copay

[someone]

You can't trust the customer support people. Most likely, they don't know what a CGM is. I think your odds of winning any type of legal battle over what you were told by the customer support person at Wells Fargo are very slim. I don't think it's worth it.

[Experimental]

A person with diabetes can still get around on their own without a CGM as diabetics have been doing it for tens of years with no problems. If the condition is so severe that you can't do that, then you obviously have numerous hospital logs from going there often, at which case that proof alone would most likely be enough for medical necessity.

Home glucose monitoring was demonstrated to improve glycemic control of type 1 diabetes in the late 1970s, and the first meters were marketed for home use around 1980. Thats only 27 years ago before that Test strips that changed color and could be read "visually", without a meter, were also widely used in the 1980s.

The CGM is a better up to date technology and that is why I am fighting for it.

[JediSkipdogg]

Home glucose monitoring was demonstrated to improve glycemic control of type 1 diabetes in the late 1970s, and the first meters were marketed for home use around 1980. Thats only 27 years ago before that Test strips that changed color and could be read "visually", without a meter, were also widely used in the 1980s.

The CGM is a better up to date technology and that is why I am fighting for it.

That is true, but it hasn't been fully proven yet in reports. There have been short term reports but they have all had to many other variables in them to get a true understanding how effective a CGM alone is.

So once it's proven effective in a long term study (which one is underway to be completed in 2010) then CGM won't be easily covered by insurance.

[Funnygrl]

I order from this company since my insurance at this time covers everything Diabetes related except the insulin as a durable good meaning I have no copay I do however get the bill sent to me before and after the provider discount.
The CGM is the first thing that I have ever had denied by this company. They are even paying for diasocks. Which are sold at $84.00 for a 6 pack before the provider discount.

I realize there prices to regular consumers is a rip but until the CGM not being approved EVERYTHING was covered with no copay
Then why does that $1000 for sets add into your $3k for CGMS? You're confusing me here, just a tad.

[Experimental]

It doesn't add into the 3K cost for the CGMS. If Wells Fargo would allow me to pay there negoated pricing for the CGM then the cost would lower. The problem I am facing is that Wells Fargo considered it experimental and investigational meaning I have to pay the regular pricing from Edgepark which is a rip. All my future sensors have since been ordered directly from Medtronic. which has been costing me approx 350 a month.

Edgepark has their suplies so marked up it's rediculious but they only supply durable goods and I have never had any products denied before.

I got screwed since the initial order was not covered by insurance. :)

[someone]

It doesn't add into the 3K cost for the CGMS. If Wells Fargo would allow me to pay there negoated pricing for the CGM then the cost would lower. The problem I am facing is that Wells Fargo considered it experimental and investigational meaning I have to pay the regular pricing from Edgepark which is a rip. All my future sensors have since been ordered directly from Medtronic. which has been costing me approx 350 a month.

Edgepark has their suplies so marked up it's rediculious but they only supply durable goods and I have never had any products denied before.

I got screwed since the initial order was not covered by insurance. :)

As far as I'm aware, insurance companies are currently paying full price for CGM sensors. This is perhaps the reason some of the companies have been reluctant to cover it.

[Experimental]

As far as I'm aware, insurance companies are currently paying full price for CGM sensors. This is perhaps the reason some of the companies have been reluctant to cover it.

Makes sense to me:) I guess I'll be testing my fingers more often while i'm awake untill they see the benefit of a CGM