What to do when insurer says no

I’m being treated for low testosterone with androgel hormone.  I just received a notice that my plan will not continue to pay for the treatment.  Can I sue them?  It is medically necessary, and they pay for female hormones for women. It seems like gender discrimination.

Manly Man

Dear Manly Man,

You cannot sue the health plan, but you can make them reconsider their decision.  By law, the plan has to have what is called an “appeals process”.  The notice that you received should have described how you start the appeal.

The first step will have the plan do what is called an internal review.  For this, a staff person who was not involved with the original decision will look at your case.  The staff person may reverse the original decision, and the plan will pay.  If the person agrees with the original decision, you will get another notice which again will have a description of another appeals process.

The second appeals process is called an external review.  An outside company – again, a person who was not involved with the original decision or the internal review – will look at your case.  They will make a decision and send you a notice.  This is your final chance to get a different decision.

Your doctor will play an important part of all of this.  He or she, or the practice manager, will give the plan additional information about why the treatment is needed.  They are familiar with these kinds of problems, and will work with you to get it covered.

Linda Riddell

About Linda Riddell

A published author and health policy analyst with 25 years’ experience, Linda Riddell's goal is to alleviate the widespread ailment of not knowing what your health plan can do for you.