Lifetime cap on DME!!???

dahliasinbloom · 08-25-2004, 09:47 AM

My insurance company has a policy of a limetime maximum payment on durable medical equipment of $2,500, per diagnosis.

When I called to get coverage for a wheelchair, I was told that I should get a note from my doctor stating that there has been a pathological change in my condition (i.e. new diagnosis)

I'm not playing this game. I'm fighting because this policy needs to change
Has anyone else seen this policy before. In the last 24 years since I've been in a wheelchair, I have never heard of a lifetime cap on DME. My other insurance companies have always covered a new chair every 5 years.

Has anyone else heard or dealt with this policy before??

thanks, Jan

Andy · 08-25-2004, 03:26 PM

Sounds like a feature-poor policy marketed at a low price point. Always a good idea to read the limitations of a policy before buying into it. Is this a group policy from an employer? If so maybe time to let others know about what shoddy coverage is being provided under the guise of "benefits".

dahliasinbloom · 08-25-2004, 10:01 PM

Yes, this is an employee health plan. My husband is a PT at an Adventist Health hospital. The ins. co. is CCN, big company.

I sent a letter to them and cc'd the Human Resouces dept. at the hospital, along with the DME provider and dept. head where my husband works. Bottom line, I wrote, is that until this policy is changed, I won't have DME coverage unless my husband was to quit his job and go to work somewhere else. I called today and they said I should have an answer by the end of this week or early next.

No way I'm asking my doc to write a letter saying my condition has changed - they're going to have to deal with me on this one.

Anyone heard of this policy before... from a big insurance company?

SCI-Nurse · 08-25-2004, 10:12 PM

I would have a talk with the CEO of his workplace and lay out the impact their choice of a cheap plan with poor coverage has for their employees and their families. Unfortunately limits such as this are not that unusual. I have had a number of clients which have group plan "insurance" that has NO DME coverage at all. If this is allowed by laws in your state, they can get away with it.

I would at least get a copy of this book and see if it is any help in fighting this company:

http://www.josephromanolaw.com/english/book.html

(KLD)

08-25-2004, 09:47 AM	#1
dahliasinbloom Senior Member Join Date: Oct 2001 Location: California Posts: 347	Lifetime cap on DME!!??? My insurance company has a policy of a limetime maximum payment on durable medical equipment of $2,500, per diagnosis. When I called to get coverage for a wheelchair, I was told that I should get a note from my doctor stating that there has been a pathological change in my condition (i.e. new diagnosis) I'm not playing this game. I'm fighting because this policy needs to change Has anyone else seen this policy before. In the last 24 years since I've been in a wheelchair, I have never heard of a lifetime cap on DME. My other insurance companies have always covered a new chair every 5 years. Has anyone else heard or dealt with this policy before?? thanks, Jan

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08-25-2004, 03:26 PM	#2
Andy Senior Member Join Date: Jun 2003 Location: Chicago IL Posts: 4,658	Sounds like a feature-poor policy marketed at a low price point. Always a good idea to read the limitations of a policy before buying into it. Is this a group policy from an employer? If so maybe time to let others know about what shoddy coverage is being provided under the guise of "benefits".

08-25-2004, 10:01 PM	#3
dahliasinbloom Senior Member Join Date: Oct 2001 Location: California Posts: 347	Yes, this is an employee health plan. My husband is a PT at an Adventist Health hospital. The ins. co. is CCN, big company. I sent a letter to them and cc'd the Human Resouces dept. at the hospital, along with the DME provider and dept. head where my husband works. Bottom line, I wrote, is that until this policy is changed, I won't have DME coverage unless my husband was to quit his job and go to work somewhere else. I called today and they said I should have an answer by the end of this week or early next. No way I'm asking my doc to write a letter saying my condition has changed - they're going to have to deal with me on this one. Anyone heard of this policy before... from a big insurance company?

08-25-2004, 10:12 PM	#4
SCI-Nurse Moderator Join Date: Jul 2001 Location: USA Posts: 41,344	I would have a talk with the CEO of his workplace and lay out the impact their choice of a cheap plan with poor coverage has for their employees and their families. Unfortunately limits such as this are not that unusual. I have had a number of clients which have group plan "insurance" that has NO DME coverage at all. If this is allowed by laws in your state, they can get away with it. I would at least get a copy of this book and see if it is any help in fighting this company: http://www.josephromanolaw.com/english/book.html (KLD)