won insurance denial for surgery

[Georgie]

Our daughter had the modquad at 15 months. She is now 29 months old. At the time our insurance company did not approve us to go to TCH for surgery. We went ahead with the surgery anyway. When we returned from TCH our long battle to have our insurance company pay for surgery started. We lost both the 1st and 2nd level appeals. They denied us because they said that the surgery wasn't medically necessary. The in network Dr said that he would have waited until she was at least 4 yrs old so that she would cooperate with the intensive rehab therapy needed following surgery. Little did he know that we've been doing ROM every single day, with her cooperating and not cooperating. I thought this was the worst reasoning. Well we decided to fight our case at the highest level with the Attorney General's Office/Insurance Commissioner in our state. They received all the correspondence between our insurance company and ourselves, and reversed the decision to deny us. We were absolutely elated. You get to point that you begin to think that nothing positive will become of this (OBPI, because everything is a fight, whether it be for more therapy, or doctor's visits, the battle never ends. But now I have regained some faith because we WON!!! We still have a long hill battle, she will be having capsodelisis surgery in Feb, but for now we are enjoying this moment. I finally feel like someone outside of my family, is understanding what we are going through. Feel free to email me watcher@home.com

Georgie

[njbirk]

What a wonderful and inspiring story. Your tenacity has paid off. It did not come without a struggle but because you knew you were right you pressed on and it was worth it!

Bravo!
Nancy

[admin]

Great news! Did you use an attorney during this process?

[admin]

Great news! Did you use an attorney during this process?

[francine]

I'm very happy for you! If you are interested, can you write up all the steps you had to take and I'll put it on maia's website...maybe it can help the next person with these kinds of problems!

francine@injurednewborn.com

So glad for you though...hope you don't have to fight too hard for the next surgery.

-francine

[Debbie]

that is great news! i am happy for you!

[Kathleen]

Great going glad to see you stuck to it and YOU WON!!!! great lesson for obpi child never give up.....
Kath

[TNT1999]

Georgie, I'm so glad that things worked out for you. Congratulations on such a wonderful victory!! I'm sorry to hear that Gabi will need more surgery. Have you gotten approval for that one yet or will you have to go through the appeal process again? I'm very interested b/c we might have to change to that insurance company in January. Also, fyi, a friend of mine has the same insurance co., but they have a different type of policy. It costs more, but gives them added benefits with a % that they have to pay to go out of network. For ex. I think she can go out of network and pay 20% while they pay 80%. Email me if you want to get in touch with her. Also, please reply here or email me about getting the cap surgery approved. Thank you! Again, congrats to your whole family! How did Gabi like the show the other night? Nicole enjoyed it, but she must've been tired b/c she sat on my Mom's lap or mine the whole time. I would've expected her to stand up and dance. At least she sang though. Take care. -Tina