Insurance denied claims from months ago - lactose free formula

[Marieb425]

Hi Everyone,

Just wanted to share what happened to us related to my husband’s Liquid Hope formula. Last fall I checked in with the hospital that dispenses the formula/supplies and they verified the coverage and told me it was covered and what the estimated cost would be. I did not double check it because my life is busy (caring for two young kids and my PALS). I also didn’t really notice that the claims weren’t being processed until we received Explanation Of Benefits last week dating back to January and saying that they denied his formula because it’s excluded from our plan. The estimated bill cost was upwards of $8,000.

I checked back in with the hospital that dispenses it and they were like oh we made a mistake - your plan doesn’t cover this formula. But they also couldn’t tell me why not or information on what formula IS covered.

I spent an hour and a half on the phone with Premera yesterday and they said the Liquid Hope is not covered because they don’t cover any lactose free formula products. I told them that I view this as somewhat discriminatory as my husband is Asian and Lactose intolerant. Ralph has tolerated this formula exceptionally well with no GI upset.

I decided to file a complaint with the WA state insurance commissioner but I don’t know if anything will come of it.

What I thought was interesting is that one of the Premera customer service agents told me that they cover lactose free baby formula …

 

[winterj]

Would it many any difference if the formula (or similar) was required by a doctor?

 

[Marieb425]

Winterj - from what I understand (after a confusing long phone call with Premera) there are no exceptions made. But I don’t fully understand it and the nurse at his ALS clinic also agrees they should be covering other options for people. My PALS is not on Medicare and he’s on Premera which is through my work. I did file a complaint with the WA state insurance commissioner office and we’ll see if anything comes of that.

 

[lgelb]

Like all registered plans, Premera also has to allow you an appeal process. It should be on the denial statement. Quite often, if you follow the procedure, they don't want the hassle and will roll over. If not, that is more documentation for your State complaint.

 

[Marieb425]

Thanks Laurie, I was just looking at the appeals information yesterday but didn’t fill out the paperwork for that yet. They have to reply by August 19th to the state insurance commissioner office. I filed the complaint and I was surprised that they sent a letter to Premera that same day!

 

[Marieb425]

Here is the update (file attached with personal info removed). Moral of the story - don’t give up!

 

[winterj]

Congratulations Marie!