US. Insurance question
Jim DeWees
Description
Collection
Title:
US. Insurance question
Creator:
Jim DeWees
Date:
12/19/2011
Text:
Hello Everyone,
This past week, a new patient came to my office for a new BK prosthetic leg. They are self employed (small business, farming) and have had their individual policy for 8 years, and of course have had to update the contract/policy each year.
The patient was involved in a farming injury as a child, which damaged the ankle joint and also her foot. She has lived with a foot that is several sizes smaller than her other foot, and a fused ankle, and no achilles tendon at all. The pain of this has progressed to a level that she could not tolerate anymore, and opted for a BK amputation. I was able to get her connected with a good surgeon that did the Ertl procedure on her, and she has healed quickly and nicely.
When doing her insurance verification and all, it was revealed that there is an annual cap of $4000 per year, and also a lifetime cap. This is a policy with Anthem.
My office is in Indiana, and the patient lives in Indiana, and this is a state that has parity legislation that passed in 2007. According to the state law, this insurance company cannot have an annual cap or lifetime cap that is different than the benefits for other medical services.
Also, the money that they pay for prosthetics is NOT included in the deductible, or is not applied against their out of pocket limits of their policy.
My question is if anyone else has dealt with this in a state with Parity legislation, and what has been the end result?
I have inquired with Anthem about this policy, and they claim that they are a multi-state company, and work as a national company, and so they do NOT have to follow the state rules or laws pertaining to coverage or benefits. They follow the national policies, etc.
This is a policy that IS through Anthem, and is NOT a self-funded policy or through a large employer which would fall under the ERISA laws.
Has anyone dealt with this? Has anyone been successful in forcing an insurance company to actually follow a state law regarding prosthetic benefits?
Please contact me privately if you have any information that could help this patient out. Or comment in public if you prefer. I will probably not compile replies, but if I do, I will not include any names or personal information.
Thanks and Merry Christmas (Happy Holidays to those that don't celebrate Christmas) to all.
Jim DeWees, CP
This past week, a new patient came to my office for a new BK prosthetic leg. They are self employed (small business, farming) and have had their individual policy for 8 years, and of course have had to update the contract/policy each year.
The patient was involved in a farming injury as a child, which damaged the ankle joint and also her foot. She has lived with a foot that is several sizes smaller than her other foot, and a fused ankle, and no achilles tendon at all. The pain of this has progressed to a level that she could not tolerate anymore, and opted for a BK amputation. I was able to get her connected with a good surgeon that did the Ertl procedure on her, and she has healed quickly and nicely.
When doing her insurance verification and all, it was revealed that there is an annual cap of $4000 per year, and also a lifetime cap. This is a policy with Anthem.
My office is in Indiana, and the patient lives in Indiana, and this is a state that has parity legislation that passed in 2007. According to the state law, this insurance company cannot have an annual cap or lifetime cap that is different than the benefits for other medical services.
Also, the money that they pay for prosthetics is NOT included in the deductible, or is not applied against their out of pocket limits of their policy.
My question is if anyone else has dealt with this in a state with Parity legislation, and what has been the end result?
I have inquired with Anthem about this policy, and they claim that they are a multi-state company, and work as a national company, and so they do NOT have to follow the state rules or laws pertaining to coverage or benefits. They follow the national policies, etc.
This is a policy that IS through Anthem, and is NOT a self-funded policy or through a large employer which would fall under the ERISA laws.
Has anyone dealt with this? Has anyone been successful in forcing an insurance company to actually follow a state law regarding prosthetic benefits?
Please contact me privately if you have any information that could help this patient out. Or comment in public if you prefer. I will probably not compile replies, but if I do, I will not include any names or personal information.
Thanks and Merry Christmas (Happy Holidays to those that don't celebrate Christmas) to all.
Jim DeWees, CP
Citation
Jim DeWees, “US. Insurance question,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/233145.
