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Self-Advocacy – What do you do when your doctor and the insurance company don’t agree?

Ms. Meniscus advises a man whose insurance company refuses to pay for his disability.

Ms Meniscus,

Today’s question [Do I Need To Go On Disability for my Rheumatoid Arthritis?] prompted me to ask what do you do when your Rheumatologist says you are not ready for work, and the disability insurance company decides that you are? The insurance co. was all gung-ho to have me go back to work in about 3 weeks’ time. I saw the Rheumatologist today and he says, “No” to going back to work, and that he would be in a better position to answer the question of when — in about 2 months. My work wants to wait until I am really well before having me back, so they are not inclined to rush the process. The Rheumatologist says he will send in a report — but what happens if the 2 cannot agree? 

Thanks in advance,

Big Ted

Dear Big Ted,

Thankfully, your rheumatologist has taken the initial necessary steps to help advocate for your situation by sending a report of your condition to your insurance company, but there is only so much a health care provider can do, considering their busy schedules alone. Your next step needs to be to make some calls to your insurance company on your own behalf. The best department to start your self-advocacy journey is at the customer relations department. Some companies may call this department something different, but if you call a general number at the company, someone should be able to direct you to the appropriate department. Make sure you carve out some time in your schedule, because this will probably be a lengthy process. 

Before making any call, I encourage you to have a copy of your rheumatologist’s report on hand. Ideally, you should also be near a fax machine or have a scanned PDF version that you could easily email to the person you speak to in customer relations. Even though your doctor has already sent the report, insurance companies tend to be very bureaucratic and disconnected. There is a chance that your doctor’s report could be sitting at the bottom of someone’s to-do list in a completely unrelated department. 

Next, be very nice and courteous to the person on the line. Their job is to help you – it’s good business to keep you as a satisfied customer. If you see that the person on the other end of the line is not interested in helping your case or seems to be giving you a hard time, hang up. Dial the number again and talk to someone else. If they tell you that they cannot help you, ask for their supervisor, and their supervisor’s supervisor until someone has the power to help you. In some cases, you will simply have to be persistent, even pushy. Call back, again and again. Keep escalating your case and eventually, you will find someone who is willing to really listen to your case and help you.

Both your rheumatologist and place of employment are behind you – these are great advantages. Since the insurance company seems to have already made its’ mind up about your situation, you will have to take up the baton and be willing to jump through some hoops in order to advocate for yourself. Confronting an insurance company can seem like a daunting task – they are vast and powerful networks, and it might seem like any attempt to make one’s point heard only falls on deaf ears, but don’t give up.

Good luck,--M

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