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<blockquote data-quote="susiestar" data-source="post: 420335" data-attributes="member: 1233"><p>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).</p><p> </p><p>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.)</p><p> </p><p>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. </p><p> </p><p>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. </p><p> </p><p>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. </p><p> </p><p>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.</p></blockquote><p></p>
[QUOTE="susiestar, post: 420335, member: 1233"] 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. [/QUOTE]
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