Michelle L. Spaulding: Insulin Pumps and HMOs
Insulin Pumps and HMOs

As soon as I understood the delivery system of an Insulin Pump I knew without a doubt that I not only wanted one, but that I needed one as well. I was sold on doing what ever it took to receive that kind of insulin coverage.

Convincing my insurer (an HMO) to pay for this form of treatment would prove extremely educational. I believed that all I needed to do was have my primary care physician write a letter in which he would recommend Insulin Pump Therapy as "a needed treatment."

It took nearly a year to receive my Insulin Pump. I hope that in sharing what transpired between my insurer and myself during that period of time will encourage and enlighten others. If you are a diabetic and have struggled with management of your diabetes, Insulin Pump Therapy has given me not only better health, it has given me back my life!

The contention of my insurer was that an Insulin Pump was a "non-covered benefit under my contract." So the big question was what did my contract really say. I'm not referring to the nice little booklet they hand out to the employees receiving the coverage either. After speaking with an attorney friend, (there's no friend like an attorney friend) he suggested I request a complete copy of all contracts, agreements, amendments or other data that constituted the agreement between my insurer and the employer. Please be aware it also took phone calls to my husband's employer as well as higher ups in the HMO to finally receive the documents. There was valuable information contained there for my use.

My perception about three months into this was that the insurer and myself each had different interpretations as to what the contract actually excluded. One of my denial letters included this exert from the contract:

The services and Benefits covered under this Agreement shall not include the following...any appliance, device, machine, apparatus, equipment or article not for the specific treatment of disease, sickness or injury....

I was elated! What I was requesting was for the "specific treatment of disease." With this information I could not possibly loose.

However, I was to learn that my contract although helpful in it's wording wasn't at all what was in dispute. It seemed at times they would just keep on saying no until I went away and gave up, but that was the last thing on my mind. Another request that was included with the contract request would prove to be the beginning of the conclusion to this battle. I requested that they advise me as soon as possible as to what steps were contractually required before litigation or arbitration (love those attorneys).

It seems I had been on a journey through what my insurer referred to as "The Grievance Procedure." It would all end with a committee meeting that would include two non-insurance company employees, and a physician not familiar with my case. The committee's decision for coverage of the Insulin Pump would be final.

I was sent a notebook with an inch and a half of correspondents between myself and my insurer. It also included all internal documents, phone records, dates, times, replies, etc. Also present at the Grievance Committee meeting were the insurance company's Regional Vice President, Vice President of Marketing, Quality of Care/Service Director, Customer Service Coordinator and the Customer Service Secretary. I went alone with the understanding that the proceedings would be tape recorded and I would receive a copy of that tape. Before this committee I would plead my case for the coverage of Insulin Pump Therapy. Feeling out numbered, I left that meeting trying not to project what the decision might be.

When I finally received their decision I wasn't at all sure I had gotten what I had been fighting for. Their decision carried conditions that at first I felt to be unfair. I had a hard time stopping the fight in me that had gone on for so long. The committee's decision was as follows:

The insulin pump alone would not improve control of diabetes. There were important responsibilities for myself which included diet, exercise and careful monitoring of blood sugars. The insurance company would purchase the pump and charge me 50% of that cost providing I would supply them with detailed logs prior to that purchase which were to include: blood sugar monitoring results including date, time, and a 2:00 am reading, insulin injections including date, time, dose, and type of insulin; and a detailed food diary. This log was to be completed at least one day each week. The HMO would finance the cost over three years without interest. The terms were for the cost of the pump with tax. For the first year I would make twelve equal payments. At the end of the first year I will have paid 20% of the total with the remaining 30% to be divided over two additional years.

Right here I asked the committee to, at the very least cover 80% of the cost. I pointed out that most insurers were doing no less. The next paragraph that followed made the previous conditions easier to swallow.

The insurer was willing to waive the second and third year payments if I was able to demonstrate improved control of my diabetes. If at the end of the first year my hemoglobin A1C results are 10 or lower, they will waive the next 12 months payments, with the same condition on the third year payments. 80% of the total I could deal with.

When starting on the pump my hemoglobin results were 11, within 8 weeks I had hit 9. Today I am at an all time low for me of 8.5. So I guess we really do know who won, ME!

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Published 17 May 1997

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