Work with Your Company

Tips for Working with Your Insurance Company

1.   Don’t get angry, get involved. Be persistent and polite because you deserve the safe and effective treatment prescribed by your doctor.

2.   Be prepared when you visit your doctor. Before you visit your doctor, prepare a list of questions you may have. Take a pen and paper along with you so you can take notes.

3.   Ask your doctor for help. Ask him/her to write a “letter of medical necessity” about the treatment in question. Thank your doctor and his/her staff.

4.   Contact a claims representative at your insurance company. A claims representative can also advocate for your case.

5.   Contact the company that manufactures the treatment in question. Many drug companies and device manufacturers have staff that can help with your insurance problems.

6.   Keep thorough records of all phone calls, letters and contacts with your doctor and insurance company. Keep records of the different medications you have tried.

7.   Be ready to educate. Assume the claims representatives at your insurance company have never even heard of SADS conditions or long QT syndrome.

8.   Notify the insurance company of your intent to appeal. If your claim for treatment is denied, send them a letter appealing the decision. Request a free copy of your policy. Ask them to accept information from the SADS Foundation as part of your appeal.

9.   Contact the SADS Foundation. We can provide a supportive letter on your behalf.

10. Notify your department of human resources (HR). If you receive health insurance through work, the HR purchased the plan on your behalf. Your employer is a customer of the insurance company, so enlisting the help of your HR department can be helpful. Your employer should understand the effect your SADS condition has on your personal and work life and that the insurance policy used at work does not allow you to access the medication or treatment you need.

12. Contact your state insurance commission to report the insurance company. In addition to the internal review of appeals conducted by a health plan, many states also conduct “external reviews” or “independent reviews.” Once an individual has exhausted his/her avenues for appeal within the health plan, most appeals are eligible for external review by the state. Conducted by an individual or a panel who is not part of the health plan, an external review resolves disputes between patients and their health plans. For a listing of programs available in your state, visit the Kaiser Family Foundation Web site.