Isn't This Discrimination?

[suzy_q2010]

Originally Posted by Charles

Any way you can get the doctor to re-assess the condition to something that is covered?

That would be fraud. Not a good idea.

[Charles]

Originally Posted by suzy_q2010

That would be fraud. Not a good idea.

Not necessarily. If Doctor A thinks it is a cold and Doctor B thinks it is allergies and allergies are covered and colds are not covered, then submit Doctor B's report to insurance.

Happens all the time. Perfectly legal.

I had a doctor write a prescription for a spa (an above ground backyard spa) for "aches and pains". Was able to deduct part of those costs on my taxes.

Perfectly legal.

[Marlow]

Wait to have it reprocessed and if it still is not making sense to you, have an attorney who specializes in health care law review it for you and advise you. Whatever you, try to do it quickly because there may be short appeal deadlines.

As others have said, if they disclosed it to you, it's probably legal. But it sounds like even the insurance company representatives are unclear about what the policy covers and what it excludes, so there may be good arguments for coverage.

Good luck!

[h886]

Originally Posted by canudigit

Thanks for your replies. The reason why I don't think it's legal, or at the very least is discrimination, is because they will cover counseling as long as the diagnosis is major depression, so how can that diagnosis be okay for one type of service but not another? Also, they cover substance abuse, which is, let's call it what it is, a disease brought on by a voluntary choice to abuse drugs or alcohol, but they don't cover depression, which is an involuntary medical condition caused by a chemical imbalance in the brain that you're born with?

I am going to pursue other avenues if they don't fix this issue. They are going to resubmit the claim, so maybe they realized when I called and brought it to their attention that they screwed up. If not, I will get a healthcare attorney involved.

Thanks again.

This is actually quite common. You have to read your policy and know what it covers. Do I think they should cover this? Sure! But that's pretty much irrelevant. There are things that I think my insurance should cover that they don't. The insurance companies are trying to do business too. As much as you wish they were in it solely to help people, etc (and maybe some people are), they are also in it to make a profit. Otherwise there's no point for them, right?

So in order to do that, they decide what should reasonably be covered. If they pay for anything and everything under the sun, the cost goes up for them, and by default, the cost goes up for every one of us too. For example, if you decide to have 40 cosmetic surgeries that are unnecessary, or if I decide it would be best for my mental health to go into a luxury inpatient resort to the tune of $100,000 a week. They set these limitations for the people who would likely abuse them and to keep costs down for everyone.

So mental health is a tricky thing. It's often misunderstood, and sadly, I note that you seem to harbor some discriminatory feelings of your own. You think your husband's situation (depression) is very important and deserves treatment. Yet you would make light of someone with addiction, saying, "Also, they cover substance abuse, which is, let's call it what it is, a disease brought on by a voluntary choice to abuse drugs or alcohol." Let me tell you, that just as many people think substance abuse is something you're predisposed to as well, an imbalance in your brain chemistry that makes you much more likely to become addicted. The way you characterize it here is no different from the people who would look at your husband, shrug, and say, "Depression? Good grief, why don't you just be happy? Why should I pay for you to get treated for that?" It is no more a "voluntary choice" for someone to be an addict than it is for your husband to be depressed. Personally, I think both are legit and both should be covered, but it is what it is.

But in any case, yes, it's legal, and no, it's not discrimination. It means you need to carefully read your policy.

[lenora]

Although I'm guessing the OPs spouse received services in Michigan, it's unclear as to whether the terms of the policy are valid. Insurance companies do not have absolute discretion in terms of providing for certain benefits. The policies must still comply with both State and Federal Law.

[canudigit]

I'm updating this thread as a public service to those of you who have had services denied by your insurance carrier:

I called the insurance company shortly after I started this thread and the lady who told me that my dh's diagnosis wasn't covered didn't seem 100% like she knew what she was doing, so I asked her if she would re-submit the claim to the healthcare provider and she said she would. One day last week, I got another statement from the insurance company stating that they paid all but 10% of the claim. AFTER THEY TOLD ME THAT NONE OF IT WAS ELIGIBLE FOR COVERAGE. Lesson learned: Never, NEVER accept what one phone operator at an insurance company tells you as the final word, and especially don't accept those statements that they send out telling you what they wouldn't pay as the final word without at least talking to someone. Insurance companies are in business to make money. One way that they depend on to do that is by having customers who do not question claim denials, they just pay what they're told to pay. That is not being a good consumer. If I had not pursued this, I would be looking at a $9,000+ hospital bill, instead of one for just under $900.

BTW, dh is doing great and things are great between us and with our family. We are truly blessed.