Legal Question in Disability Law in Pennsylvania
insurance company not paying benefits
My son is 20 years old and severely disabled both mnetlaly and physically. My husband's employer's health care plan was changed in March of 2005 to a new provider. The previous provider paid my son's medical claims without any problems. The new one at first refused to pay any claims stating he was too old to be covered. I contacted them as they do provide coverage for disabled dependents. I was required to have a physician complete a 20 page detailed document to cerify him as disabled. They then began paying some of his claims. As he needed more expensive items such as leg braces or a new wheelchair they did not want to pay the benefits. The physicians write detailed letters explaining the medical necessity of the items. Some the ins. company even pre-authorizes but then fails to pay a large portion with reasons that my son's coverage doesn;t provide for the items even though i have pre-determination letters from them stating the items are covered under his policy. When I try to appeal their non-payment I get letters saying that based on my son's age I am not able to appeal for him even though they are fully aware he is not capable of acting on his own behalf. What can I do? I can't afford to pay these medical bills.
1 Answer from Attorneys
Re: insurance company not paying benefits
It sounds like this insurance company is trying to make things difficult for you. Now that your son is no longer a minor, you may encounter difficulties (like this matter) in obtaining services and benefits on his behalf. Accordingly, you should consider filing a petition with the court to become the plenary guardian of your son's person and estate. This will give you the authority to handle matters on his behalf. You will need an attorney to handle this matter. You may also need an attorney to compel the insurance company to provide the benefits that it is required to under its contract.
Feel free to contact me on this matter to discuss further.
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