This is not industry-related at all but I’ve had a fair few questions about how I fought my insurance company and won — twice — by using all my Karen energy for good. So, I figured I’d jot it down in one easy place & share the link far and wide! A lot of people think that insurance is the Final Word; it isn’t. Not by a long shot. You have the power to appeal decisions and you have the ability to raise holy hell to get your needs met. Here’s how.
I have fought my medical insurance (self-bought, via the state marketplace) twice and won both times. I have also appealed a car insurance decision and won.
The first time I went up against my insurance was for birth control. They covered the name brand of a medication I was on but not the generic. I preferred the generic (bodies are weird; for some reason, it just worked better for me) and they refused to cover it.
This doesn’t fly. This is illegal. AHCA plans are required by law to cover birth control — ALL birth control. It doesn’t matter if the medication I want isn’t covered by my plan; it’s a preventative medication and I have the right to appeal their decision to deny coverage. I asked my doctor to submit a prior authorization form on my behalf. That’s usually step one after the denial. If that is ALSO denied, which this was, you can submit an appeal. I sent a letter to my insurance company (they’ll include an address — again, they HAVE TO, BY LAW, tell you how to appeal) outlining exactly what laws they were skirting by refusing my coverage. In that letter, I told them that I would be sending a copy to the state department of insurance* and I expected their (the insurance company) full cooperation with the law.
They now cover the medication I prefer at 100%, as they are bound to do by law. This took about a month. It was annoying but it was a relatively painless process.
…Less so my migraine medication. I currently use Ajovy, sumatriptan nose sprays, and Botox for migraine control. The combination of Ajovy and Botox has been fucking magical but my insurance tried not to cover Ajovy using a whole bevy of excuses. At first it was “this medication isn’t covered”, then when we went the prior authorization route they whined about how I couldn’t do both Ajovy AND Botox.
They asked for my doctor’s office to fax them migraine journals, which we did, and they denied for a third time.
IT IS ALWAYS YOUR RIGHT TO REQUEST AN INDEPENDENT MEDICAL REVIEW.
I filed another claim with my state’s department of insurance after they denied me again and demanded an IMR (independent medical review). My doctor and I submitted all of my paperwork again, this time to the state. They read over it, told my insurance to quit being such raging assholes, and bam: Ajovy covered. It’s still expensive (450 a year! yowch) but it’s covered.
Bottom line: you can do this. You can fight these people. You are in charge of your health. If your doctor or insurance won’t go to bat for you, force them.
This is true for any appeal of any insurance decision: be clear, use facts, and send copies everywhere. No one at your insurance company cares how you feel; they operate in numbers, in laws, and very little else. “My pain is an 8/10 on 25 days out of a 30 day month” is a fact to health insurance. “I really like this medication” is not. “The other party broke CA Traffic Code Number Whatever by doing XYZ” will work. “I really think I checked my mirrors” will not. Documentation (photos, doctor records, etc.) should ALWAYS be attached.
*Your state’s department of insurance can be found by simply googling “STATE NAME department of insurance”. From there, scour their website for ‘file a complaint’ or similar. Mine, for example, is: http://www.insurance.ca.gov/01-consumers/101-help/index.cfm