Wednesday, March 16, 2011

Insurance Woes

So yesterday afternoon while going through the mail, I got three letters from our health insurance company. Every time I see mail from United Healthcare I cringe because it's usually some kind of letter that requires me to spend an hour on the phone with UHC and then more time off the phone collecting papers and documents. And yesterday was no exception, all three letters were full of bad news for Stephen and his Mom. They rejected our request to pay for his formula and protein supplement, his Synagis injection, and our request to see the pulminologists whom saw him in the NICU and who already know his lung health history.

I figured they would reject the request to cover the costs of his formula, but I thought they might cover the cost of the protein supplement. But I NEVER thought they would reject the request for the synagis vaccine. Synagis is extremely important for Stephen and all sick babies. It is the only FDA-approved vaccine to protect high-risk babies' lungs from the respiratory virus, RSV. RSV has been very prevalent in our area and if Stephen gets RSV, he's sure to be sent to the PICU for quite awhile. Luckily, Stephen received two out of three of his synagis while in the NICU, so we only need one more shot to get him through cold and flu season.

The letter states, "Your doctor has requested Synagis for your child. However, your child is not in a high risk group that meets the criteria for additional Synagis use."

Seriously?!?! What part of spending 59 days in the NICU, having NO kidneys, a compromised immune system, and being on a ventilator for a period time doesn't put you in a high risk group?!? In my eyes, Stephen is the very definition of high risk! And thankfully his pediatricians and his pulminologist both agree. Luckily as soon as the pediatricians heard this, they immediately petitioned our insurance company to cover this.

Now I just need to work on getting them to cover Stephen's formula and supplements. He needs the extra protein which he cannot get from breast milk or formula alone, but most importantly he has to have formula because you can't put breast milk in a feeding pump. Which should be reason enough for insurance to cover it. And his "recipe" for formula is 1,000 times more concentrated than a normal baby. Instead of the 2small scoops of formula per batch, it's a half cup of powder per days feeding. That equates to one can of formula every three days.

I'm telling you, I think they make health insurance so confusing so that people just give up and do whatever they tell you instead of fighting it. As much as it drives me absolutely crazy, I vow to win over insurance and get these things paid for!! Now if only I could clone myself and have one Lindsey to do paperwork and phone calls and another Lindsey to hold little Stephen all day!


  1. Will you have him get his final vaccination against RSV anyway? And then fight with the company? My perfectly healthy, full-term baby caught RSV when she was just under a year. Ended up on nebulizer treatments forever, and has developed asthma, several bouts of bronchitis and pneumonia, all thanks to the orginal RSV, according to our pediatrician. (coincidentally, we live in Northern VA, and in Arlington at the time, so yes, very prevalent here). Seems to me that it would be good for insurance companies to cover ALL kids against it, not just high risk kids. I would think the preventative shots would be cheaper than the consequences of contracting RSV (even in our daughter's case, who was not hospitalized, but is still on inhalers at the age of 3 that insurance pays for). Insurance companies don't seem to follow the same line of logic...

  2. Hi Lindsey,
    Thank you for sharing your experience, you, Bill and Stephen are constantly in our prayers.
    My mother runs a maternal/child health program for the state of SC so I shared your woes with her and she offered the following:
    1. Virginia has a plan called IDEA Part C - fed program admin. by the state available to all newborns, no income limits and its there to help families get the services they need/and deserve
    2. If you're on SSDI, you get medicaid automatically-maybe you know this.
    3. Your doctor needs to write a "big" letter to get the Synagis approved. My mother has to argue for it in every case
    4. State Health departments have chilrdren rehab programs, may be income limits but it doesnt hurt to ask
    5. my mother knows the woman who runs the state prgram for children and mothers in Richmond - administers fed dollars to hospitals for families - I will text Billy her contact information once I receive it tomorrow.
    Hope this helps, let me know if you have any other questions. -