[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.

[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]

Originally Posted by moorejames

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]

Originally Posted by JediSkipdogg

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]

Originally Posted by Experimental

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]

Originally Posted by Experimental

My infusion sets would be $1000 a month

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