HMO appeals

[frankie2]

What is the name of your state? IL

My daughter used up the plan benefits. I was told that I could appeal to get her additional benefits, but that was denied also, not based solely on available benefits, NOT on medical necessity. Is there anything at all I can do?

Thank you.What is the name of your state?

 

[cbg]

Not really. When the plan benefits are used up, they're used up, and nothing in the law says that just because you can appeal for more benefits you are guaranteed to receive more benefits.

You are owed benefits as defined and described by the policy. Anything over and above that is a privilege, not a right. When you have received the maximum benefits allowed under the insurance contract, unless a state law mandates a different and higher level of that particular benefit, that's all you are owed.

 

[frankie2]

Thank you, CBG

I appreciate your response. And I do understand why that is. My daughter's condition is worsening and causing a flood of other medical problems. Is there anything that would help the insurance company to understand that by giving her additional limited benefits, it will benefit them by not having her max out her benefits again next year?

I'm just trying to do as much as I can for my daughter. I'm not trying to swindle the insurance company.

 

[cbg]

I understand that; I'm not accusing you of trying to get something you aren't entitled to. Just explaining how it works, since many people do not understand that the insurance carrier is only obligated to pay what the contract says and no more. They frequently believe that the insurer is obligated by law to pay for anything medically necessary, regardless of what the insurance contract says. Couldn't tell from your post if you were one of them or not. (Even if you were, I'm not going to blame you for not understanding something as complicated as insurance law! )

I'm sure the insurance carrier understands that your daughter might max out the plan again next year. The problem is, if her problems are as bad as that, she might max them out anyway whether they offer her additional benefits or not. You can try to explain your reasoning to them; you can ask your doctor to try. But the bottom line is, without language in the contract that guarantees you additional benefits under certain circumstances and those circumstances have been met, they have no legal obligation to grant additional benefits no matter how much better it would be for them in the long term to do so.

 

[frankie2]

Thank you again!

Just wanted to thank you again. I greatly appreciate your reply!

 

[cbg]

Hope it goes well for you both.

 

[ecmst12]

You could, however, check with your state's Medicaid office. Some states offer medicaid benefits for children with serious illnesses or chronic disabilities, for situations just like yours where they could exhaust their insurance benefits every year or even the lifetime maximum.

 

[frankie2]

Thank you for the advice!

I will call the state's Medicaid office after the holiday. I appreciate the tip.