Post # 1
I am so beyond frustrated with my health insurance company right now. My four year old daughter’s prosthesis (which we got a whopping 1 month ago) is malfunctioning and causing her to knee to be hyperextended to the rear and if we don’t stop the hyperextension she will likely need surgery on her knee. Dr. and prosthetist agree, it needs to be scrapped and start over with a new one. My health insurance just changed their coverage of “durable medical devices” (wheel chairs, crutches, etc) to 80/20 coverage (approx $3,000) but prosthetics are still covered at 100%. Now they are trying to tell me that her prosthetic is actually not a prosthetic but instead is a durable medical device. I just spent 45 minutes on the phone with the insurance company, explaining that her new prosthesis is a prosthesis (covered 100%) not a durable medical device (covered 80/20). They did suggest, as a cost saving option for us, that if we opt not to replace her prosthetic leg any surgery she needs to repair her knee would be covered at 100%!!! Gee thanks!!!
I am so frustrated I could spit nails right now. Oh, they did agree to review the claim to determine if her prosthetic leg is in fact a prosthesis.
Post # 3
@MrsFuzzyFace: But hey, they offered a great alternative. Who doesn’t love surgery?
Insurance companies suck. They will loophole anything they can. I got rear ended at a red light (I had been stopped for a while), the guy admitted it was his fault, but our two insurance companies took their sweet ass time fighting over who was to blame before I could fix my car. It was just a small scrape, but still. Pissed me off.
Post # 4
@Pinkmoon: Oh yes, the insurance company suggesting free surgery, after her knee becomes horribly instable, for my four year old makes me see red. I guess there is no cost to them for the pre and post surgery pain of a small child.
Post # 5
Unbelievable that they would even suggest that surgery would be a cheaper option! I’m just stunned by that (and angry for you!).
But what I don’t get is, if according to the insurer, a prothesis isn’t a prothesis, then what is a prothesis? If a prothesis dosen’t qualify as one and is instead classified as a durable medical device, then what, exactly, does qualify as a prothesis?
Post # 6
@Neva: This is exactly what I spent 45 minutes trying to find out. I still didn’t get an answer, but I am starting to believe that nothing qualifies as a prosthesis.
Post # 7
I am so sorry you have to go through this. Insurance companies are beyond frustrating to deal with. Could you try making an argument that since the prosthetic is defective and was purchased before the date the insurance changed their coverage, they have to replace it?
Post # 8
@MrsTillerResq: The current prosthesis was made by a different prosthetist who refuses to admit that it is not working. I went to a new prosthetist when he denied there was a problem (it is a pride thing, I am sure). If he sees no problem and refuses to sign off on the medical need for a new prosthesis, we have to start over.
Post # 9
@MrsFuzzyFace: I hate my insurance too. I’m sorry but I’m pretty sure it would be cheaper for the insurance to just cover a new prosthesis vs all the surgeries for after the knee is ruined. I hate that they seem to avoid covering preventive care when it would be cheaper for them but instead they rather have to pay for the costly surgeries/rehabilitation after the damage is done.
My parents insurance will not pay for my dad to go to treatment for alcoholism but dont worry cause its ok since they cover all the testing and other costs to try to fix his liver. Gah! it could have just been avoided completely. Sorry end rant.
I hope you tear them a new one and get a new corrected one with them covering in full like they are supposed to.
Post # 10
@MrsFuzzyFace: That’s just stupid of them! Hopefully they’ll change their minds because you aren’t rolling over for them.
@Pinkmoon: Did you get a police report when the accident happened.