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When I was first diagnosed we had Cigna insurance company. They would not pay for my doctor visits, medications or anything.
They claimed that TS was a mental disease in which I was self manifesting my problems and that there was nothing medically wrong with me to warrant treatment. At that time insurance companies were not forced to provide mental health coverage.
My mother, bless her heart, fought with the insurance company constantly and in the end I got covered. I wish I could tell you exactly how that went but I was just the child. I am trying to get her to possibly visit this website and detail the process she went through. All I can do now is outline it.
First of all, if 100 people in the same state that use the same insurance company and they refuse to cover all 100 they just saved a lot of money. If only 3 families fight and they decide to pay the 3 that fight, they still saved 97 other payments. Unfortunately that is how the insurance companies think.
Second of all, I know that insurance companies have a process for fighting a claim. My mother initiated that process many times, she would appeal the appeals to her appeals, and eventually at one point made as far as driving down to have a meeting with the top executives of the company to testify in front of a panel of executives. She won that case and they paid for everything after that.
Un fortunately my fathers work changed insurance, my father ended up changing jobs several times and I must have had 3 or 4 different insurance companies all during the time I was regularly seeing a doctor and was on medication. Each time we changed companies my poor mother had to start all over again.
Each time she got better, it was easier, and i know if I could get her to come she could probably provide much better insight into this topic. From what I understand, anytime you visit a doctor for any reason, the doctor bills the insurance company for you. That paperwork uses an industry standard set of "codes", a numbering system that tells the insurance company what kind of visit it was.
The book, I believe, is called the DSM4. It is like a master list of all the medical / insurance codes for appointments. One thing that helped our cause was my mother purchasing this book. She read through the codes and discovered that much of the time one appointment might be able to fall under several different codes. The "standard" code for TS related doctor visits was flagged by the insurance company as a type that is or was not covered by our specific policy. They would refuse to pay automatically and no person ever even looked at the billing for my visits.
I guess, my mother was able to request to my doctor that the billing code be changed to another code that was also appropriate and that often got the insurance company to pay. In the beginning we had to make sure that my visits were listed as medical visits and not mental visits - but then congress passed a law that stated mental and medical coverage had to be the same and I guess that also made it a lot easier for my mom to fight with the insurance company.
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I know this may not be very helpful to you, someone who is looking for help with the insurance company, but what I am trying to get accross is that you cant give up - you have to fight to get yourself, or your child covered. I hate to hear that people can't get the medicine they need because they cant afford it when they also have insurance that should cover it. They expect you to not fight, they expect you to give up. Don't ever give up. There is hope.
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