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    Post: Advice Regarding Health Insurance Appeal

    Posted by LK on 5/24/08

    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.). Iím 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 personís
    annual income while she awaits other services), and the
    services are medically necessary.

    Thanks in advance!

    Posts on this thread, including this one
  • Advice Regarding Health Insurance Appeal, 5/24/08, by LK.

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