3. Visit your insurer's website. Look for any policy statements related to your condition, and review the services your individual plan covers. Learn your rights and responsibilities for requesting coverage.
4. Engage someone at your health plan. It could be a nurse case manager or the medical director. And insist that the insurer follow its own rules. "Oftentimes, an insurer may have a legitimate reason for being concerned about a test or a treatment, but they have to follow a specific process" for denying a claim or pre-authorizing a service, Santa said. "Your request may or may not be covered, but the insurer has an obligation to provide due process."
5. Appeal. If you're not satisfied with your plan's response, don't be afraid to go through the appeals process. "The track record on appeals is favorable," Santa said. "There's a good chance you could win." In the case of autism, make sure your treatment plan is medically focused and targets deficits in social interaction, communication and repetitive or restrictive behaviors, said Kristin Jacobson, the president of Autism Deserves Equal Coverage, an advocacy group in Burlingame, Calif. "Health plans make it very hard for families," she said. "They count on families giving up. The ones who don't give up are the ones who eventually will prevail."
6. Beware of signing long-term contracts. Some TMJ patients have gotten locked into multiyear contracts with health care providers and continue having to pay long after they've stopped treatment, Cowley said. "In the event that the treatment doesn't work or you are worse, you are still obligated to pay that contract."
7. Maximize your benefits. If you have another medical condition that overlaps with the one you can't get coverage for, treat the one that is covered. Children with autism whose family health plans exclude that diagnosis, for instance, might find some relief by pursuing coverage for related conditions such as speech or motor-skills delays, Jacobson said. Your health plan also may have a separate disease-management program, for which you might qualify, that could help you with pain management or diabetes, should you need it.
8. Consider hiring a private health care advocate. Choose someone who has handled many cases similar to yours. You can search for professional advocates near you at AdvoConnection.com and the database of the National Association of Healthcare Advocacy Consultants.
VIDEO ON MSN MONEY
More bad advice from MSN on insurance matters. Health insurance is most often provided under an employee sponsored plan and, thus, governed by the Employee Retirement Income Security Act (ERISA). What most people don't understand about ERISA is that it gives an "administrator' of the plan discretion to determine if a procedure is covered or not. If you do end up suing the Plan for coverage, the Judge does not determine if the administrator was write or wrong, only whether the administrator abused his/her discretion in denyimg the coverage. Thus, an administrators decision could be wrong and the coverge denial will still be upheld - so long as the administrators decision was not "arbitrary or caprecious."
Also, the trial does not allow the insured to submit evidence or call witness (except in limited circumstances). Instead, the judge "reviews the record" - i.e. - what you submitted in support of coverage vs. what the insurance company relied on in making its determination. Who do you suppose has its case better documented? The insurance company, of course.
And, the insurance company will set you up for failure in this regard by telling you that the appeal process (which is the record on review) is a simple process - all you have to do is requst a reconsideration of the decision. When your appeal is denied, therefore, you have nothing to support your case when the judge makes his decision.
If you have been denied coverage, and the costs of treatment are significant, seek the advice of a lawyer who is experienced in ERISA law immediately. Waiting until the appeal process has been exhausted will severly reduce your chance of a successful outcome.
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