Some of you might recall me mentioning on occasion how I was fighting Tricare (our insurance) for them to cover boost shakes for Mark.
The initial deinal was back in September of 2004. Since then I have appealed 6 times and finally, because we paid out of pocket over $50.00, we could have a hearing.
So, back in January we had a hearing with a federal judge. He represented nobody, but rather heard the case I presented to him and submitted a transcript of the hearing to Tricare and to Tricare's lawyers. I had 2 months to submit a written closing arguement (I could have done a closing argument at the hearing, or submitted one in writing, so I choose the latter) which I did. Then All of that was sumitted to Tricare and their lawyers. They were going to have until August 18th to have their argument/closing statement submitted and then I'd have 1 week to rebuttal their statement(s) if necessary.
The judges place in this whole hearing is to look at my side of the arguement, and Tricare's side of the arguement and then make an educated and legal recommendation to Tricare. Tricare does not have to do what the judge recommends (hence "recommendation") but it is advisable in most cases.
Well.... I just got THE phone call this morning from one of Tricare's lawyers. He said, "we've decided to allow cost-sharing of this Boost shake for your husband and you should recieve our letter of appoval by the COB next week". (cost share means we'll have a copay, but they will pay the rest!!!!). He also told me they were notifying the judge.
I am so excited, absolutely thrilled. After almost years of fighting this, WE WON!!!! I'm really proud and happy too because I have worked by butt off on this case. My closing statement was 4 pages, but then had 82 pages of enclosures and 5 letters from Mark's various CF doctors and dieticians and I even got the CF foundation to help me out with this one, they wrote a letter (not included in the 82pages) and submitted some information on CF and malnutrition and supplements.
I have 2 gigantic binders FULL of correspondence/appeals over the last 2 years, plus all of this stuff for the hearing and the closing argument.
<b>I remember a while ago some other Tricare people were asking me to let them know if we won, We've kind of set a presedence for this kind of coverage for CFers with pancreatic insufficency with this insurance company. If anyone wants a copy of our closing argument so they too can fight Tricare, just email me.</b>
I've changed my email (too many hotmail problems). It is now division902@verizon.net
The initial deinal was back in September of 2004. Since then I have appealed 6 times and finally, because we paid out of pocket over $50.00, we could have a hearing.
So, back in January we had a hearing with a federal judge. He represented nobody, but rather heard the case I presented to him and submitted a transcript of the hearing to Tricare and to Tricare's lawyers. I had 2 months to submit a written closing arguement (I could have done a closing argument at the hearing, or submitted one in writing, so I choose the latter) which I did. Then All of that was sumitted to Tricare and their lawyers. They were going to have until August 18th to have their argument/closing statement submitted and then I'd have 1 week to rebuttal their statement(s) if necessary.
The judges place in this whole hearing is to look at my side of the arguement, and Tricare's side of the arguement and then make an educated and legal recommendation to Tricare. Tricare does not have to do what the judge recommends (hence "recommendation") but it is advisable in most cases.
Well.... I just got THE phone call this morning from one of Tricare's lawyers. He said, "we've decided to allow cost-sharing of this Boost shake for your husband and you should recieve our letter of appoval by the COB next week". (cost share means we'll have a copay, but they will pay the rest!!!!). He also told me they were notifying the judge.
I am so excited, absolutely thrilled. After almost years of fighting this, WE WON!!!! I'm really proud and happy too because I have worked by butt off on this case. My closing statement was 4 pages, but then had 82 pages of enclosures and 5 letters from Mark's various CF doctors and dieticians and I even got the CF foundation to help me out with this one, they wrote a letter (not included in the 82pages) and submitted some information on CF and malnutrition and supplements.
I have 2 gigantic binders FULL of correspondence/appeals over the last 2 years, plus all of this stuff for the hearing and the closing argument.
<b>I remember a while ago some other Tricare people were asking me to let them know if we won, We've kind of set a presedence for this kind of coverage for CFers with pancreatic insufficency with this insurance company. If anyone wants a copy of our closing argument so they too can fight Tricare, just email me.</b>
I've changed my email (too many hotmail problems). It is now division902@verizon.net