Employer says "not medically necessary"

[shanny06978]

What is the name of your state? FL

My Mom found out she has 3 bone spurs, extreme nerve damage and the equivalent of carpal tunnel in her foot. They prescribed her these funky shoe inserts to alleviate the terrible pain she is in. If these do the trick, she will not need surgery. If they don't work on their own, she will need surgery and still need to use the inserts to correct something in her leg. ANYWAY, she called her insurance, BCBS, because they are not covering one centof the cost of the inserts. They told her that the company she works for is the one saying these are denied. That was the way the policy is written. She works for Amerigas propane company and I don't think that they are medically competent enough to make that call. Is this legal? Can anyone direct me to information on this practice? How scary is that!?! Any help you can offer in trying to get this resolved would be wonderful. Thank you!

 

[karihager1982]

I don't know a lot about situations like this - but I do not believe that her actual employer 'Amerigas' can make a decision like that.

That is WHY they HAVE insurance - the insurance company is supposed to determine stuff like this. To me it sounds weird. I cannot be 100% sure though - hopefully someone else can answer this better for you.

 

[BlondiePB]

What is the name of your state? FL

My Mom found out she has 3 bone spurs, extreme nerve damage and the equivalent of carpal tunnel in her foot. They prescribed her these funky shoe inserts to alleviate the terrible pain she is in. If these do the trick, she will not need surgery. If they don't work on their own, she will need surgery and still need to use the inserts to correct something in her leg. ANYWAY, she called her insurance, BCBS, because they are not covering one centof the cost of the inserts. They told her that the company she works for is the one saying these are denied. That was the way the policy is written. She works for Amerigas propane company and I don't think that they are medically competent enough to make that call. Is this legal? Can anyone direct me to information on this practice? How scary is that!?! Any help you can offer in trying to get this resolved would be wonderful. Thank you!

You need to read the insurance policy regarding devices that are medically necessary and what devices are covered even if they are medically necessary and even if the beneficiary has a prescription for it. Even though something is medically necessary and one has a prescription for it, it does not necessarily mean that the medically necessary device is covered under an insurance plan. Personally, I do not think the person at BCBS knew what he/she was talking about in regards to the employer's approval regarding the insurance policy. You just never know these days, though. Read the policy.

 

[Beth3]

The employer is not making this decision, the insurance carrier is within the confines of the insurance policy in force. That CS rep your mother spoke with doesn't have a clue what she's talking about or else your mother misunderstood.

A great many group policies do not cover orthotics, regardless of whether they are medically necessary. Your mother needs to review the insurance certificate she received when she enrolled that describes what's covered and what's not. If after doing so she thinks her orthotics should be covered, then she may file a written appeal with the insurance carrier.