Posted by LK on 5/24/08

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Hello, and I hope I make sense as this is a complicated
question/scenario. I'm writing an insurance appeal for
failure for a PPO federal government employee health
insurance policy (a PPO) to properly pay a claim pure
contractual terms (person sees a particular provider which
is covered under certain conditions, one of which is the
diagnosis for which she sees the provider.). The person sees
this provider weekly, so this will be an ongoing issue (I'm
appealing past failure to pay claims properly.). I’m doing
this no charge.

It occurred to me that I also should make an argument for
in-network higher payment as this is also an ongoing appeal
for a person with a severe disability, for a person
currently below the poverty level, who must go
out-of-network because there is no in-network provider with
an ADA- accessible office (the person uses electric mobility
devices to ambulate). Is there anyone who can point me in
the correct direction or to the PROPER PORTION OF LAW TO
CITE? OR SOME CASES? Any other suggestions?

Attempts were made over a 3-year period to see if any
preferred providers would meet in an accessible
area/alternate office; there are a number of in-network
providers whose offices are in places where no possible
accommodation could be made to make the building accessible
(i.e., rowhouse with numerous stairs to get in to the
building and, not that this matters, then an office on the
third floor, for example, with the first two floors not
medical offices). For this particular specialty, there are
no preferred providers in accessible buildings.

The company not required to provide any in-network providers
for all specialties; my thinking, though is that if they
provide an in-network provider that is accepting patient but
has an inaccessible office that the company then has some
responsibilities (i.e. to have an in-network provider with
an accessible office or to pay an in-network rate for a
provider with an accessible office).

Thanks for any help you can provide! I am recovering from
surgery and have no one to whom I can refer this matter. A
large sum of money is involved (more than this person’s
annual income while she awaits other services), and the
services are medically necessary.

Thanks in advance!

Advice Regarding Health Insurance Appeal, 5/24/08, by LK.

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