Waiting and hoping.

I know I’m setting myself up for disappointment but I finally broke down and went to HR to discuss our horrid insurance company.   We have Tufts Health Plan, an HMO.  Between the company contribution and our contribution we are paying close to $2,000/month for this plan and they are worthless.

They paid for Monkey’s evaluation at the FX clinic but they refused to pay for any of the therapies that were recommended.  They will not pay for any OT, they will not pay for the autism evaluation, they will not pay for his folic acid, the limits on ST are drastic enough that it’s not even worth using.  Beyond Monkey’s situation they will not pay for IVF but they will pay for the PGD.

Every time we visit the FX clinic it’s a battle.  We get the referrals, they refuse to pay.  We play by their rules and still have to jump through hoop after hoop after hoop.  One of our bills from last June nearly went to collections in December because they couldn’t get their act together.  No one could figure out why they weren’t paying it.  We had to get an extension from the hospital to avoid a black mark on our credit over something that was not our fault.

The insurance company that we had before HR made the switch?  They cover ALL of this.  Every last penny would be covered and our co-pays would be $10 cheaper per office visit.  AND because of the universal healthcare law here in MA I could buy this plan for $12/month less than what the company and I are paying now.

I was, and still am, furious over this.  Being a parent is not easy.  Being a parent to a kid with special needs is even less easy.  We spend all of our waking hours some days managing him. When bedtime arrives we are exhausted just about every night.  On top of all that we spend hours and HOURS of our lives negotiating bureaucratic bullshit.  From the school, from the insurance company. 

It’s enough to make a girl cry and cry I did when I started to explain to the HR director what all of this added stress does to our family.  I told him we need these things.  Monkey needs these things.  We can’t afford to spend what we’re spending on this health plan and not get anything out of it.  We can’t afford to spend what we’re spending on this health plan and then spend an additional $2,000 a month out of pocket on the therapies that other health plans would cover.  

I told him quite frankly that this is going to play a significant role in my decision to stay with the company or not.  Monkey and his development are too important for me to not consider this very seriously.  He asked me to give him time to call the insurance company and try to navigate the situation for me.  We have a small window of time to file an appeal of our latest rejection and he wants to try to avoid that.  So do I, I don’t want to have to hire a freaking attorney to get my insurance company to pay for a medically necessary, diagnostic test for crying out loud.

Argh.  So…I’m waiting and hoping that for just ONCE the insurance company makes this easy.  I am bound to be disappointed though.  *sigh*

5 thoughts on “Waiting and hoping.

  • February 27, 2009 at 11:29 pm

    Good for you standing up for what is right for you and your family.
    Life truly sucks and those in power rule the world with nothing helping out the little people.

    Keep the faith — maybe something good will come out of it.

  • March 1, 2009 at 12:12 am

    How frustrating. So sorry to hear this. I’ve also spent hours on the phone – including trying to get our insurance company to pay for the FX test itself – which turned out to be positive as you know – but they are still not sure it was “medically necessary”! Won’t your school district pay for OT and some of the therapies? Or are they just as difficult to deal with?

  • March 1, 2009 at 7:14 am

    I hope you get some good news. Have your company considered switching back since the cost is the same, and the benifits so much better. I too am dealing with new, bad insurance, compared to what I had at my job. Joel’s company is small, so its not the greatest plan. So far I have been lucky to get all of our services through the regional center. I dread when we go to the school system, and if they don;t cover things. We are also looking into IVF-PGD, and I am afraid to even ask what is covered.

    Good Luck!

  • March 1, 2009 at 6:54 pm

    Right Sarah, the FX test was just “educational,” right? I’ve heard the same about getting my test done.

    The school district does pay for some but it is limited. He gets an hour of OT/week (two 30 minute sessions) when the school is in session. He gets no therapy during school vacations or during summer break. Also, they suggestion was for him to get additional OT geared towards sensory integration which is different than what he gets in school (they do mostly fine motor which is also important.)

  • March 1, 2009 at 6:59 pm

    Holly’s Mom, they won’t discuss insurance with us beyond trying to problem solve with the current plan. If they were to switch again we (employees) would be the last to know. I am not the only person having problems with this insurance company. There is a woman who had a kidney transplant some years ago and the current insurance company tried to deny paying for her anti-rejection drugs!

    Our EI services were excellent, the school district is a bit more challenging to deal with because the focus shifts. In EI they were always looking for ways to best serve Monkey and the entire family. In the school they are simply looking at what they need to provide for him to make “adequate yearly progress.” What they decide is adequate doesn’t always match up to what we think is adequate 🙂


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