As of tomorrow...

Discussion in 'The Watercooler' started by Shari, Apr 14, 2011.

  1. Shari

    Shari IsItFridayYet?

    I am officially out of physical and occupational therapy benefits for my "conditions" caused by my crash.

    I have 70% functional movement in my wrist, and 60% functional movement in my ankle. I am at 50% strength in both. But ins has said I am done.

    So glad they know what's best.

    (and beyond thankful for a PT and an Occupational Therapist (OT) that are willing to barter for continued treatment. They are not kicking me to the curb. They'll just be working for an extremely reduced rate now.)

    And I think I will not hesitate to go to the doctor every time my tendonitis from lack of flexion in the ankle flares. Or for the shin splints I get when I'm on my feet all day.

    And if I pull a muscle throwing a saddle on the horse.

    All separate incidents, and all could be prescribed PT to remedy...
    Last edited: Apr 14, 2011
  2. KTMom91

    KTMom91 Well-Known Member there any way you can appeal the decision? Because you don't sound "done" to me. I thought "done" was when you were either close to 100% or couldn't progress any farther.

    Your PT and Occupational Therapist (OT) sound awesome...glad they're willing to continue working with you.
  3. Star*

    Star* call 911

    I:m with KT on this one.

    Glad to hear you're feeling "better"?

    Maybe you could ride English for a while? Lighter saddle? (oh you know I am joking? )

  4. susiestar

    susiestar Roll With It

    You are on the right track to plan to keep going back and have your doctor re-rx the PT and Occupational Therapist (OT) for "other" problems in those same areas. You can appeal the ins co decision that you are "done", but from personal experience I would not devote a lot of time and energy to it. Go with the barter and "new" diagnosis's instead and save your energy for the PT and Occupational Therapist (OT).

    Ins co's have a contract with your company and you to provide services for a fee. The actual results of an appeal depend very much on that contract. You may or may not even have increased number of sessions as an option for the appeal in your specific contract. These things are cut more and more every year because of "rising costs", meaning that the ins co tells you this whether or not their costs rise - and I pretty much doubt that they do given the enormous profits that ins co's achieve. (But that is just me.)

    Until a couple of years ago I thought the way you do - that if you were still having medical problems then the ins co HAD to keep providing services. It took a long talk with husband's sister, who manages an ins agency of a LOT of agents who write all types of policies including health ins. She explained that it generally is NOT based on your medical condition that services are approved. It is ALL based on that contract and mostly now that number can be written in stone and will not be increased unless your company is willing to buy more sessions for you. YOU don't even get the option, it is all int he fine print that you will NEVER EVER SEE because it is between ins co and your employer.

    in my opinion you are actually fortunate that your policy gives you X sessions per injury/condition. We have never had a policy that had that - ours are X per year (usually 20-30) in every ins plan we have ever been offered. We have had the option of plans that only offer 10 sessions, but never more than 30. We also have had an enormous copay, rivaling that of ER/hospital visits, for each session of Occupational Therapist (OT)/PT.

    I am sorry. Insurance plans really hoover when you are sick. I hope that they will continue to barter AND that the doctor will give you "another" diagnosis and keep doing it until you get all the PT and Occupational Therapist (OT) you need.

    Appeal rights DO vary from state to state, so it may be more worthwhile to appeal where you live than it is here. Here there is pretty much no recourse or support for an appeal. It might be very different where you live, so do check that out - possibly ask the state ins board about it.
  5. Shari

    Shari IsItFridayYet?

    I highly doubt I would get any more visits from the appeal, and as I say, its ok because my PT and Occupational Therapist (OT) are willing to continue to work for a reduced fee. It just shouldn't be this way. I had an all but severed foot and a major broken wrist...essentially 10 PT visits for each (they resulted rom one accident, so I get 20 pt visits for that accident) wouldn't even begin to cover "rehab" from that.

    So while I do plan to appeal, I also plan to see a doctor EVERY TIME I DO ANYTHING to either of these limbs. Step in a hole, get a little sprain, going to the doctor. Arthritis flare in my knee - guess where I'm going? My PT has already treated me for tendonitis twice for no additional fee. I won't make things up, but I won't ignore what I otherwise might, either.
  6. DaisyFace

    DaisyFace Love me...Love me not


    It shouldn't be that way....but for us regular folks - it is.

    Now, Representative Gabby Giffords? She's going to have therapy and services for as long as "medically necessary"....and we will continue to get news stories about her miraculous progress.

    You on the other hand, will just have to make do with "as good as it gets" (Thank goodness you are able to work out an arrangements with your therapists!)

    Don't get me wrong - I hope Rep Giffords makes a full recovery.

    It's just very sad that the rest of us don't even have that option.