The battle over health insurance

by Lesley Politi on November 12, 2008

The battle over health insurance
In the battle over health insurance, even those fortunate to have coverage may run into trouble.

It happens when you’re denied coverage for a procedure you and your doctor believe is medically necessary.

What can you do?

Five year old Keegan Hendrick is undergoing surgery for a second cochlear implant. It’s a procedure that almost didn’t happen.

Keegan and his twin brother Jet were born prematurely. Initially doctors thought Keegan was profoundly deaf. Turns out, he has Acoustic Neuropathy.

As Dr. Jason Mouzakas explains, sound waves aren’t processed properly by the cochlear, this snail shaped structure in his ears.



“That sound wave then gets to be a jumbled mess,” says Dr. Mouzakas.

A cochlear implant in his left ear corrected the hearing on that side, but he still hears static in his untreated right ear.





You can imagine how that interferes with his overall ability to hear.

“I’m noticing that he’s definitely falling behind. He’s not up to Jet. He’s definitely not up to other kids his age,” says Kara Hendrick, Keegan’s mother.

A second cochlear implant was scheduled, but the Hendricks’ health insurer, MVP said, it was not medically necessary so — request denied.


“Come to my house for a couple of days and you’ll definitely see that it’s a must,” says Hendrick.

Dr. Mouzakas was frustrated that his attempts at getting a review of the ruling fell … well … on deaf ears.

I called the Hendricks’ insurer, MVP and explained the situation. The Communications Director told me the appeal process was still open and he’d follow up. Within two weeks of our call, the Hendricks’ got the good news. A review of their case was resolved in their favor. The surgery was approved.

So what should you do if a medical procedure generally covered by your insurance is denied?

New York State law says your insurer has to grant an internal appeal.

If you lose in that round, don’t despair. Contact the State Insurance Department. It will review your case.



You can go to an independent expert that the Insurance Department will certify. An independent expert who will make that determination.

The health plan bears the cost. It costs the consumer $50. If they win, they get the money back.You and the insurer are bound by the ruling, but it’s important to remember.


You only have 45 days after your insurer denies your first internal appeal to file with the state. If you wait any longer, you lose your right to a state appeal.

At the end of the day, more than 50% of initial denials, do get overturned.

You or your doctor can ask for the State Insurance Department appeal.

This is what you’ll need: the denial notice, your subscriber contract, provider name and contact information and all the medical documentation. Make sure it’s in order.

The only way the state won’t review the case if it’s something your insurer doesn’t cover, like dental work, if they don’t cover dental.

And be proactive. Carefully read your insurance policy, know what it covers and how to appeal.

If you lose at the state level, you can sue, but remember, the fact that you lost the state appeal will be used by the insurer.


Questions call Politi Insurance Agents & Brokers



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