Insurance Problems

Insurance Problems

Avatar of Katie

Insurance Problems

July 2, 2010 in Uncategorized

As some of you may remember, I wrote a blog awhile ago about my battle with my insurance company for formula coverage. I have had the same health insurance since birth. Formula was always covered fully with a $30 copay until January 2009. That is when they decided to classify my formula – Camino Pro – as medical food. This meant I was allowed $2500 per year. Since my formula is over $700 per month, that does not get me past 3 1/2 months for the year. Long story short, I went to my clinic and had my doctors write letters stating Camino Pro is an enteral formula, not a medical food. I had Cambrooke Foods provide documentation as well. I provided my insurance company with several different copies of NYS law showing that enteral formulas MUST be covered. In addition, I found and presented them with a previous case through Aetna where the insurance company was fined over $20,000 for not providing formula. Back in September 2009 I started to actively fight my insurance company, and they continued to refuse coverage. In November, I decided to take all of my documentation and send it to the NYS Department of Insurance. After nothing was being resolved with them, I decided I needed to pursue this further. Around March 2010 I submitted once again all of my information to the New York State Attorney General office. I also mailed the paperwork to John Hall’s office – of whom I still not heard anything from!! So, I’ve been working with someone in the Attorney General’s office. We are now in the month of July and this still has not been resolved. My insurance company continuously ignores that AG office!! I am flabbergasted at how an insurance company continues to ignore the attorney general…. Needless to say, I am so beyond frustrated because my insurance company continues to try and say the only way they would cover formula is if it were through a feeding tube. I continue to argue with them that they covered formula from 1984-2009, but now they say I need to have a feeding tube for it to be covered. I could be wrong, but I believe this is against my civil rights. Let's put a feeding tube in someone when really they can just drink 3 juice packs a day! I decided when I reported it to the Attorney General; I would make a Civil Rights Complaint too. I have yet to hear from them too. I have decided when this is all said and done (and I will win!) I plan on pursuing the civil rights appeal. I am so annoyed because I am definitely not the only person who is experiencing this. It is time to put this all to an end. This whole issue has placed tremendous stress on me physically and mentally. I will not let it go, and I will fight it to the end. Not only am I going to fight this as a civil rights case for myself, but for all of the PKUers out there that cannot fight or defend themselves. I basically am writing this blog to see if anyone else has gone through this and have any suggestions for me at this point? I have been fighting this for over a year, and unfortunately feel like I am going to be fighting it for much longer. Thanks for listening and hope to hear from some of you! :) Katie, NY, 25

8 Reviews of Insurance Problems

  1. Registered: Feb 1, 2010

    Posts: 0

    Tucson, Arizona

    Wow, good job for sticking with it! One of my nursing instructors told me that she had worked for an insurance company at one point and they were instructed to say “no’ and get customers off of the phone as quickly as possible. I think they bank on people accepting the answer and not fighting, but this is ridiculous! I hope you make progress on this. When I was younger, the state insurance coverage stepped in when my parents couldn’t afford to pay and insurance wouldn’t help. When I got older and had my own coverage through my own job, they approved coverage (50%) one year but denied the next…I was quitting that job so I didn’t pursue that fight. When I got married, I got onto my husband’s insurance through tricare and the military’s insurance only took one appeal before they reversed their decision. Good luck, though I don’t have much advice for you!

  2. Registered: Apr 24, 2009

    Posts: 0

    Cornwall, New York

    Thank you. I am glad to hear it worked out for you. I have no doubt that the insurance company is told to just say “no.” However, I am speechless that they can continue to ignore an Attorney General’s Office…. and that the AG office will tolerate it for as long as they have! I could be wrong, but the NYS Insurance Dept and the health insurance companies keep telling me their lawyers are involved, but the funny thing is… I am the one who has gathered all of the legal documentation stating that my formula is in fact an enteral covered and based on NYS law should be covered, yet it is all being ignored for months now… so irritating!

  3. Registered: Oct 8, 2009

    Posts: 0

    Scarsdale, New York

    hi Katie,
    I was just reading about your insurance problem. I am in a similar situation regarding Olivia’s formula. I work for the Archdiocese of New York. My insurance company has refused to cover her formula because they consider it to be a “nutritional supplement.” Can you imagine that?!! The problem is that the AD is not governed by the state and there is no federal law concerning this. I have been arguing with them over this since we all know that the formula is medically necessary, not a supplement. I have been unsuccessful thus far and was thinking of pursuing it with the AG. I think I will, but I will also wait to see how your experience continues as you are further into the process. I think this is totally ridiculous that these companies are making coverage so difficult. Good luck!

  4. Registered: Apr 24, 2009

    Posts: 0

    Cornwall, New York

    ahhh so happy to hear from you… I truely hope I can help you right now with this… I was just blessed with a phone call yesterday (monday) from the Attorney General’s office. My insurance company finally agreed to cover my formula. They considered it medical food, not enteral formula… argue the formula to be an enteral formula, because in NY state, it is YES in fact legal for insurance companies to provide it… Call this number… 1-800-428-9071… ask for Chris Dippolito… She is who helped me through this since March at the Attorney General level… through my name in there… Katie Maguire… any other info or questions needed, email me please.. katiemag16@aol.com

    I would LOVE to help!

  5. Registered: Oct 8, 2009

    Posts: 0

    Scarsdale, New York

    Thank you so much. I just got off the phone with the Archdiocese again and now they claim the prescription company is to blame. I am going to officially appeal the denial with them this week. I will also call the number you provided to get Olivia’s situation out there. I am so glad that your ordeal is over. I hope that we will be equally as successful in our endeavor.

    Sincerely,
    Christine

  6. Registered: Apr 24, 2009

    Posts: 0

    Cornwall, New York

    Christine,
    Do NOT give up. They told me over and over NO. Do not give in. Fight them to the end. Submit an appeal to the Department of Insurance. Also, I spoke with Tim Verhaegen from NYS Dept of Insurance. His number is 518-474-9847. I would recommend calling both offices immediately as my case is fresh in their mind. They actually obtained lawyers over this case because I would not back off. Again, please let me know if you need anything. I have plenty of information regarding NYS law, medical information from doctors and Cambrooke Foods (formula company), and previous law suits to insurance companies for denying formula.

    Stick with it Christine… I cannot stress enough that you should not give up ever on this.

    Best of luck,
    Katie

  7. Registered: Feb 8, 2010

    Posts: 0

    Maysville, Kentucky

    Katie, I am sorry to hear your problem, but glad to hear that you are willing to fight. I have wondered (and worried) that this may be a problem for us in the future. Maybe if everyone contacted their states now.??….in KY there is a limit on medical foods, but I don’t think this includes the formula. We are not beyond infant formula at this point. Keep up the good work..it sounds like you have been doing all the right things!

  8. Registered: May 27, 2009

    Posts: 0

    , Florida

    It’s a shame it took so much to resolve this- you are such a warm and sweet person, to get you that riled up just demonstrates how wrong they are. Good job sticking with it- your fight was not just for you, but for other PKUers who will follow. I am proud of you for your efforts!

Add Comment Register



Comment

Your email address will not be published. Required fields are marked *

Comment *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>

Processing your request, Please wait....

    Archives

Quick Poll
Which of the following best describes you?
Parent/caregiver of an infant with PKU
Parent/caregiver of a child with PKU
Teenager with PKU
Adult with PKU
Grandparent of a child with PKU
Know someone with PKU
Healthcare professional