Help me FIGHT the INSURANCE!

[Mako]

FOLKS, run as far and fast as you can from CIGNA Healthcare. This is the worst insurance company I've ever seen in my life.

I have sleep apnea and they've ***twice denied**** me coverage for the necessary machine, a CPAP (continuous positive airway pressure). I hate the idea of wearing it but it helps so much!

I can't afford $2000 for one!

I'm on my second appeal. I also just got the Better Business Bureau involved, I filed a claim on their site just minutes ago.



How would you fight? I've got my primary physician and pulmonologist involved, but they can only point out the facts. I can't threaten to sue them, they love such things b/c it bogs down the whole process (did some research on that one). Are there any advocacy groups out there that insurance companies dread to see?

Thanks!!!!!!

Matt

[nursie]

Have they told you what the criteria that they are looking for to cover the cpap? How recent was you last sleep study. From what I understand there a certain number of times you are apnec that they are looking for, that and if you desaturate(loose o2 level). Check it out. If your numbers are close, it might be worth your while to have the study redone.

[sublime1184]

I work in Medical Billing\Health Insuance.....Humana is a known "non-payer" along with Mega Life who is now Campus Care. Avoid Humana at all costs, I have never had problems with Cigna but I think Aetna and Campus Care (previously known as Mega Life) are pretty good payers and we have not had much patients complain about them. I would try Aetna or Campus Care. I don't think you can switch in the middle of claims processing.....or Dates of Service not covered. Long story but I would try Aetna. Good luck, PM for any questions and I will find out for you if I don't know.

HTH,
Sub

[TKOS]

Was this an existing condition before you got insurance? Are they saying why they won't pay?

[flyingfish]

Hey Mako, I used to have Cigna, and I've had Aetna(only slightly better). I now have UnitedHealthcare. Anyway, as long as you meet the requirements for coverage you should be able to get what you need paid for. My experience with Cigna (and with others) was that if you are willing to be the squeeky wheel, and MAKE the insurance operator call the prescribing Doctor and all criteria are met then Cigna would finally pay up. I had to make those calls countless times. But like nursie said, find out the criteria and make sure they are met on your end, then talk to them until they'd pay you just to quit calling. Good luck, I hope you get better.

[Max]

Was this a pre existing condition as tkos said? If it was are you in a group policy that has a pre-existing conditon clause or waiting period? Most groups will wave pre-existing conditions for their member. Read your contract closely and see what it says about conditions inclusions and exclusions, generally with large groups they will let most thigns through. Do read the fine print thought and make sure that don't have any surprises for you. After all of that what I would do is call is call the insurance and commerce division for the state of South Carolina. I'm not sure what the law is there I don't have a residents license but, in my state if they deny a just claim they have to pay triple damages.
Chris
Yes, I'm an insurance broker.
Also Mako is probably stuck with who ever he's with most employers have one choice take it or leave it. Private health insurance is out of most peoples reach and the signs etc you see on the side of the road are only for a discount plan they don't usually provide much at all.
hth and pm me if you have any questions I specialise in property and casulty but, I work for one of the largest brokerages in the country.

[judgemax]

my son had apnea because of prmaturity ..we actually had to rent a cpap and oxygen and a heart moniter untill the insurance covered have you looked into home health stores or supliers in your area some have rentable or even cheap used equipment... also put an add in your local bargain sheet for the equipment...you never know! and good luck and I agree keep the calls going and keep you drs updated on the situation...i know you don't want to rent and you pay insurance for this type of thing but untill you get it taken care of its an option...apnea isnt a fun thing ,,good luck

[Mako]

Thanks folks. They way they have their nutty requirements worded, I don't meet the criteria. The problem is I don't have normal apnea. It only happens severely in REM sleep, which means basically the same bad news as someone with the more commonly known overall apnea. No good REM =no good sleep and danger to you heart and blood pressure due to the gasping.

I'm getting the BBB and the state insurance commission involved. I am also going to require that CIGNA provide documented evidence that I do NOT need CPAP. Their second denial letter contained an offer for something like that. I want to know why they think I don't need it.


You wouldn't believe the nightmares and freaky dreams that apnea causes! :devil:

[nursie]

Since you have an unusual case have you asked to have it reviewed and had your MD submit a letter of medical necessity? Insurances have physicians that review cases based on patients physician info. If you have an unusual case that doesn't fit their criteria, you should be able to request a review. Have you talked to anyone in a supervisory capacity with the insurance? I talk to insurances all the time in checking benefits for home care patients, and there are ways to get exceptional situations reviewed.
Some absolutely will not cover something, but others will review it.

[Mako]

Since you have an unusual case have you asked to have it reviewed and had your MD submit a letter of medical necessity?

Yes, and the first review (by a single MD) was done and the CPAP was denied. My doc and I both filed for a second review by a panel of "qualified individuals" whatever that means. I'll be able to have a conference call with the panel, and with luck my pulmonologist will be on that conf call as well if he's able.

I've already got the BBB involved, waiting on a reply from CIGNA. Next step is the SC Insurance Commission. There are way too many health risks that apnea brings along with it, not to mention the sleepless nights, to let this company walk all over me. We pay outrageous amounts for this insurance, so every second I spend fighting them is being the best steward I can with MY money.

[nursie]

Sounds like you are on the right track. Good luck!
Odds are the reviewing MD wasn't a pulmonoligist, just a GP on the ins payroll.

[Mako]

Likely, and he's out of the way now. Supposedly the "committee" is a group of non-previously-involved people.

All I can say is I'm convinced beyond the shadow of a doubt that the insurance companies are THE reason for any medical "crisis" we have. Being a nurse, I'm sure you know just what kinda thing I'm ranting about.