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Thread: Insurance won't pay for any preventative measures - Any advice?

  1. #1

    Insurance won't pay for any preventative measures - Any advice?

    I haven't asked my insurance to provide me with assistance in placing pillows at night to prevent bed sores because I didn't want people in my house at night. I can't place them myself so I didn't use them and luckily never had a serious sore. Now that my fiance is being payed to do my care I asked for an hour at night to place them and my insurance (WCB) has denied me. My case manager says they will only provide assistance after I get a sore!!!! This means Im supposed to risk my skin or expect my fiance to help for free. She (my manager) even said that it was his responsibility because we have a relationship. I doubt she would wake up every few hours for the rest of her life to help her husband!
    Similarily (though a bit more justifiably) they have refused to install a track lift to reduce the stress on my body of a few of my daily transfers. They will buy that if my joints deteriorate!
    This makes no sense to me! I plan to appeal but has anyone else run into a situation like this?

    "Learn from yesterday, live for today, hope for tomorrow"
    ~ Anon

  2. #2
    Emi, since I'm unfamiliar with Canada's laws, I can only advise as to what can work in the US. Insurance decisions are based on the basis of an arbitrary determination of "medical necessity". Consumers (us) need to educate their physicians and health care professionals on submitting requests for medically necessary goods and services. A good justification for equipment is the time/money it can save in personal care assistance hours or the specific basic tasks it enables you to do, that you can no longer do because of your SCI. Research has shown the many requests are routinely denied, regardless of merit, because consumers will not pursue the issue. My advice, appeal, appeal, appeal. The US has assistive technology projects in each state to help with these strategies. Affiliated with the (ATP's) are Protection and Advocacy non-profit legal agencies, trained in the specific laws that govern public and private insurance programs. Perhaps you can do research to determine if anything similar exists in Canada. Alaska has an ATP, as well.

  3. #3
    Emi, when my son came home from rehab, the therapists had recommended a low air loss mattress for prevention of sores, because at his level of injury he was at greater risk. Medicaid turned us down, saying they only covered that type of mattress if there was an existing skin breakdown! I know- it makes absolutely no sense; they're able to cover the cost of a skin breakdown, including flap surgery and hospital stay, but not the relatively small expenditure to provide a little prevention! I've given up trying to figure out the reasoning of health care beaurocrats!

    Now, having just moved to SOuth Carolina, we are finding out that Medicaid here will only cover 4 meds a month! Matt is on Ditropan, Hytrin, 2 different doses of Lamictal(for seizure prevention), Reminyl (a cognitive med), and Renacidin irrigation. Not to mention the occasional wound care or antibiotics. How do you roll the dice??????

    _____________
    Tough times don't last - tough people do.

  4. #4
    i have always wondered about this, it seems so counter-productive.
    i wanted to go for some PT sessions a few years ago, but my ins. co. won't pay for "on-going physical therapy to prevent further physical deterioration".
    if i fall apart at the seams, then they'll pay for me to be fixed, as long as any PT i need is at the same hospital where they fix me and no more than 7 (i think) visits.
    idiots.
    edited to say i didn't appeal because i never submitted a claim......what they would and would not pay for was published in the "owner's manual" you get from them.

  5. #5
    Senior Member
    Join Date
    Oct 2001
    Location
    Canada
    Posts
    112
    Hi Emi!
    I'm in AB too and had the exact same problem. My case manager said I'd be able to transfer into the shower with time and practise. The only thing that happened was I didn't shower. Yuck. We requested funds thru homecare (wcb wasn't involved)for a lift system and were denied, appealed and denied again. They said to apply again in 6 months if there was no improvement in the situation. So I wasn't going to shower for 6 months? SH*T! I finally just sucked it up and bought a lift.
    Stick to your guns and fight it out. Don't let them get away with it!
    Also continue fighting for the extra time for the help at night. My hubby helped me in the night (I had to cath a 3am for a while--long story) for the first few weeks, when I got out of rehab. He burnt out very quickly. Luckily a few mean letters and calls to homecare gave us someone to come in to help me in the night.

    Off the topic, when you were preggo (congrats on your daughter!) did you have to increase how many times you cathed in the day, or did you start cathing in the middle of the night?

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