mama bear start the year (rage against the insurance company)

By | 11:47 AM 6 comments

We had Eli's surgery scheduled for this friday. But in lieu of having the surgery we are instead waged in a war with our insurance company who sent us a nice letter stating they are denying coverage of the surgery. Nice, eh.

And since we don't have a spare $64,000 we are appealing their decision.

Not so appealing.


Eli is worth it. And as his mother I am his advocate.

For those of you interested in the medical details you can read below. If not, I won't bore you... just skip down to the bottom.

Eli has a very abnormally shaped head. You can't tell this from most pictures of him as the abnormality doesn't translate through pictures. We have had two ct scans done and seen several specialists who agree that it hasn't affected his brain, but was created as a result as his positioning (or rather, lack of proper positioning) as a baby and young toddler. And while the surgery is not a life or death is medically justified. It is something that will impact the rest of his life if not fixed.

Folks, we can't even get a bike helmet to fit on his head.

How can they say it is not needed?

I want to walk him through the cubicle mazes of the insurance company and bring along a bike helmet and invite the powers that be that decide these things to try and get it on his head.

But instead I am rationally getting second opinions, rounding up letters from specialists and pediatricians, taking pictures, and googling the mess out of how to write an effective insurance appeal. Any suggestions are welcome!

Am I frustrated? Yes.
Am I worried? No.

I know that the Lord wouldn't have provided every. single. penny. we needed to bring him home only to stop now.

I was just hoping it wouldn't have to be such a fight.


Bring out the mama bear in me. Eli is worth it.
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Anonymous said...

This page has some very good points to include in an appeal letter (for example, the difference between cosmetic and reconstructive surgery and examples of reconstructive surgeries that are commonly covered by insurance)

Kathleen said...

Don't even get me started on fighting insurance companies. I wish you much success!

Susan said...

Hey! I feel your pain. If I remember correctly, his surgery is planned at Duke, right? If so (and you haven't tried this yet), try to call the surgeon and explain this problem with his/her nurse. We ran into lots of obstacles two years ago with Fred's surgery, treatment, etc, and every single time an insurance conflict occurred, Duke helped us get through it. I can also guess who your ins. co. is, too (based on Jeremiah's!). In the past year, there have been (more than usual) hoops for us to go through for even little doctor's office visits to get them to pay! Be persistent and determined!

I am the mom said...

I'm not certain she can help you, but you can also try calling Chris's mom. She works in vascular surgery but she pulls quite a bit of clout from what I understand and she definitely knows the ins and outs of Duke hospital! 681-2406

Kelly Via said...

I am so frustrated for you. I'll be praying for the appeal and that the surgery will be covered. (And, for momma bear;) )

Kurt said...

Why don't you go down there? Their offices are behind the Harris Teeter on MLK Blvd. I believe the name of the person you wan't to see is Dr Palumbo. (Could be mistaken, since it has been a while since I have dealt with them!!)