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Old 02-10-19, 10:49 AM
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Re: The what's bothering you RIGHT NOW thread Part V

Quote:
Originally Posted by sarahsweets View Post
The only reason I won my appeal was because I went into my husband's human resources department and laid it all out for them. It started in July when the three a day I was on was no longer covered anymore. I had been trying to get 4 covered because I was on three a day of xr and 1 of ir and wanted all xr-plus I had a vacation override so I think internally I triggered some kind of review. Its funny that these companies act like their review and appeal process is even helpful or possible. Of course they dont want to pay so they say no. I started with the patient advocacy that his employer offers to advocate on the behalf of the patient. 2 months of calls, lost paperwork, poor communication in the insurance depart. The advocate gets on the phone and is the nasty one. So after all that I was left with my doctor needing to have
"peer reviewed cited scientific evidence " for a final appeal. That is when I snapped. Went into HR and laid it out with records of all I had done thus far. Told them my theory based on the fact that it was a controlled substance and asked them why an insurance company is allowed to make medical decisions in place of my doctor when previously they must have had evidence that I did indeed need at least three a day and all of a sudden they determined I did not. All this time I was told I had to pay for it in order to demonstrate a justifiable need- meaning if I need it this bad I would even pay for it. I saved all my receipts. I was assigned an individual from the insurance company that actually had a phone number I could call but I stayed up HR's butt about it. All of a sudden last week I found out it would be covered and they called the pharmacy and were able to re-process about 6 claims. I need to go back into my receipts and find out if there are any unleft that I could get processed. Again- since July this has been a thing. I encourage anyone who has a halfway decent HR department to try their luck with them should you fail because over all they respond to you directly and are more affected by your personal story and evidence.
It’s nice to see someone take on “the man” and win. Way to stick with it.
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