Saturday, May 30, 2009

Are you stupid, or just an @sshole?

When we first started TTC, we were told that our insurance covered fertility services.  Then, in the time between the clinic required testing (STD screening, HSG, psych eval.) and our first IUI, our insurance company stopped covering our fertility services.  We were not told about the change until I was leaving the clinic after my first IUI.  Our insurance company had decided that I did not meet the criteria for infertility, so we would have to pay for everything out of pocket.  

The eligibility requirements  for infertility, as stated by the insurance company are as follows:

Infertility services are covered for any abnormal function of the reproductive systems such that you are not able to:

*Impregnate another person
*Conceive after 2 years if the female partner is under 35 years old, or one year if the female partner is 35 years or older, or if one partner is considered medically sterile.
*Carry a pregnancy to live birth

Excellent, we thought.  We'll just write to the insurance company and appeal their decision not to cover us.  After all, their policy seems to indicate that infertility is based on whether or not a COUPLE can conceive together.  If I were with a man, I would automatically be covered if my husband was sterile.  Since Elizabeth can't produce sperm, these eligibility requirements should apply to us.  
We wrote to the insurance company, and about a week later they said that our case would be reviewed by the board, and we could make our case via phone during the meeting if we wanted to.  So we did the teleconferenced meeting, and made a good case.  Unfortunately the insurance company upheld their decision not to cover our IUIs, but told us we could do a second level appeal.  We did a second level appeal to the insurance company, and a few weeks later got a letter back stating that our request to have coverage for IVF was denied.  

Ummm, IVF?  Where the hell did that come from?  We were only asking for coverage for IUI, which costs a fraction of IVF.  Of course we wouldn't expect IVF coverage at this stage of the game.  So we did a third level of appeal, which required us to write to the State Department of Pensions and Benefits. We re-stated our original argument, but added the fact that the insurance company didn't even know what procedure we were going for, indicating that they weren't taking our claim seriously.  The state wrote back a few days later, and told us that they were making the insurance company complete an expedited final review of our case.  Apparently, expedited means tremendously slow, because it took 3 1/2 months for the insurance company to give their final decision.  And guess what they said...


The insurance company should know that IVF and IUI are NOT interchangeable terms.  So I've come to the conclusion that they're either really stupid, or else they're very intelligent, calculating @ssholes.  It wouldn't surprise me to find out that somewhere along the line, an insurance company employee had "accidentally" changed IUI to IVF just so that the insurance company could deny our appeal.  Why else would they continue to write about IVF, even after we'd made a point of correcting them on that?  Maybe I've just seen one too many M.ichael M.oore movies, but I'm convinced that they're doing everything in their power to waste our time, string us along, and make us give up on the appeal.


Pufferfish said...

Oh, I hate that you are having to go through this. Unfortunately, this is pretty standard protocol for a lot of health orgs.
When we had to figure out the correct answer--even though they could clearly see there were two women listed on ONE insurance policy--we decided to pick option Number 2:
"*Conceive after 2 years if the female partner is under 35 years old, or one year if the female partner is 35 years or older"
and state that yes, I had been having unprotected sex for 2 years and had not been able to get pregnant.
And see, that's not really a lie...because they can't ask follow-up questions.

I don't know if it's too late to work with you...sounds like it might be.

As far as the IVF vs IUI mix-up. Urgh. Sometimes ppl just don't have a clue.

Anonymous said...

I am sorry that you are experiencing such a mess. I feel as if the gay population is making so much progress in so many areas of society and rights--and then there is a moment like this. It is very discouraging to live in a world that looks through heterosexual colored glasses.

thebao said...

How weird that the insurance company can't tell the difference between IVF and IUI. I've encountered that when telling nonmedical people that we're going to try to get pregnant, and they immediately ask if IVF is how that's done. It's one thing from laypeople who just don't know enough, but it's something else entirely when medical professionals, including the nurses and doctors who must have had to review your case, don't know the difference. That is effed.

Anonymous said...

I vote asshole, just because ;)

The whole insurance scam really sucks. Here in NZ, no fertility treatment is covered by insurance no matter what the situation. We're lucky though in that we do (eventually) qualify (potentially) for govt funding (possibly) after 12 unsuccessful IUIs (if you fit the other criteria). But then there is the waiting lists to contend with... nothing is simple.

The mix up between IUI/IVF though is inexcusable. Even if they feel the need to use an umbrella term, you would expect their medical experts to come up with something more fitting.

Justine said...

this just sucks so much. i don't even know what to say. except that i hope you can somehow get through to them and their evil ways. (and, it's totally some weird conspiracy. i'd be out of my mind.)

hope you are able to do something that makes you feel a little better. we're thinking of you here.