ASK THE INSURANCE EXPERT
ASK THE INSURANCE EXPERT
Karen Pollitz is Project Director at the Institute for Health Care Research and Policy at Georgetown University in Washington, DC .
Q
Medical books clearly state that TS is a neurological disorder, but some insurance companies deny claims on the basis that TS is a mental condition. How can I convince my insurance company to cover my claims?A
Almost all health plans have a formal appeals system. You should insist that the denial be reviewed and ask your doctor to help you submit reasons why your care should be covered. If the plan upholds its denial, you should call your state’s insurance commission—check the National Association of Insurance Commissioners web page www.naic.org. A growing number of states allow consumers to appeal health plan denials to an independent body of medical experts and their decision is binding.The insurance department in your state may not be able to help in every case, e.g. many employer-sponsored health plans are exempt from state regulation but the commissioners are a good resource for information.
Q
Can I choose to have my neurologist as my primary care physician?A
It depends on your health plan. A small but growing number of state managed care protection laws require that patients with chronic illnesses can designate their specialist to coordinate all their medical care. If this is not the case in your plan, try requesting a "standing" referral so that you can see your neurologist without first seeking approval from your primary care physician.The U.S. Congress and some of the states are debating legislation to expand access to specialists for people with chronic conditions. You may want to express your views to your state and federal representatives.
Q
My health plan doesn’t have any of the neurologists or psychiatrists from TSA’s referral list. How can I encourage my insurance company to include one or more of these doctors in their list?A
Start by asking the plan directly. If you have health benefits through your job, you may want to ask your employer to make this request of the plan, as well. You should also contact your state insurance department. Some states have rules regarding the adequacy of the managed care networks—making your concerns known to the regulators may be worthwhile. Some insurance plans also offer ‘point of service’ options that permit you to see doctors outside the network. These plans usually reimburse only part of the cost of out-of-network doctors and you will be liable for the difference.Q
My twenty-one-year-old son is a part-time student with a part-time job. He is too old to be covered under my insurance. Are there any state programs that will cover him?A
The answer varies from state to state. Researchers at Georgetown University have written a guide that outlines consumer rights in every state — http://www.healthinsuranceinfo.netQ
I have contacted three insurance companies trying to obtain health coverage for my husband. As soon as they learn he has TS, they refuse to offer him a standard package, increase his premiums, limit his doctor visits, or deny our application altogether. Is there anything we can do?A
This depends on the kind of coverage you seek and where you live. Your legal rights are greatest if you are trying to get coverage under a group health plan. It is illegal for group health plans in every state to single you and your husband out in any of the ways you mentioned. If you are trying to buy individual coverage your rights will vary from state to state. Check out the free state-by-state consumer guides at http://www.healthinsuranceinfo.net.