When Insurance Says ‘No’

By Codi Darnell
November 1, 2022

As a society, we’ve gotten to a place where we have insurance for everything. From homes and vehicles to travel, pets, and health, we take out policies and spend thousands of dollars each year because we believe it means we’re protected. We sleep better at night thinking we are financially covered in the case of a fire, an accident, an illness, or one of the other dozens of what if scenarios that play out in our minds. Insurance is a comfort and for individuals who live with conditions that require the daily use of medical supplies, equipment, and medications, having health insurance often means freedom from having to choose between a functioning body and bankruptcy.

Beyond the havoc that medical conditions unleash on the body, they can also get very expensive very quickly. It seems obvious that insurance would approve the costs of the tools required to give an individual the best quality of life, but claims are denied every day. According to the AARP, over 200 million healthcare claims are denied daily in the United States. This leaves people either in a battle of appeals while scrambling to find the finances to pay out-of-pocket or going without life-giving medical supplies and equipment.

With that in mind, I spoke to two individuals who often deal with health insurance. Derek Lavender and Olivia Bender are both wheelchair users from the United States who recently had important claims denied by their respective insurance companies. Their stories are just two of many who are forced into bargaining for their health.

Wheelchair Denied

In June 2016, Derek Lavender sustained a spinal cord injury in a motorcycle accident leaving him paralyzed from the chest down. His need for a lightweight manual wheelchair seemed like a simple ask – a necessity to move forward in recovery and in life. But when insurance still hadn’t processed the claim by January of the following year, the Lavenders ended up paying for his wheelchair out-of-pocket.

The price of custom wheelchairs can vary, but the cost is never minimal. As Derek says, “Chairs are like cars. You can get all sorts of different bells and whistles.” But a chair that meets his needs, sits around US$10,000.

Between medical professionals and insurance, the typical agreed upon lifespan of a manual wheelchair is about five years. With that knowledge, Derek began working with insurance again in June 2021. Now, over a year (and several rounds of appeals) later, he is still waiting on approval for a new wheelchair. Why? Because insurance approved a power-assisted device two years prior and decided he can just rely on that.

Without insurance coverage, the only way forward is to stick with the old wheelchair or pay out-of-pocket once again. For now, Derek is thankful his current chair is still meeting his needs, but he says he’s “hoping (but not holding my breath) that they will approve a new chair before this one is no longer functioning”.

As Derek aptly points out, “Insurance is very here and now. They don’t tend to think ahead 10 years of the surgeries/rehabilitation/care required for an inevitable shoulder repair.” A proper wheelchair not only serves his mobility needs in the present but will also help to maintain his overall health – meaning he is less likely to require additional medical care in the future.

No Catheters, No Big Problem

Oliva Bender has been a full-time wheelchair user for 13 years due to transverse myelitis, an autoimmune disease that presents much like a spinal cord injury. Because of her condition, Olivia’s bladder is unable to release urine meaning she cannot urinate without the use of a catheter. And if she doesn’t empty her bladder, she runs a very real risk of infection or even a ruptured bladder, both of which could lead to multiple complications, including death.

A three-month supply of catheters for Olivia comes with a price tag of about $3,000 and, again, this seems like a simple ask; urinating is a necessity of life and it is something Olivia’s body is unable to do. But when she started a new job with new insurance, her claim for catheters was denied without explanation – just a No.

Oliva is thankful to have Medicare as secondary insurance but doesn’t know if they will cover the catheters. If they do not, she will be personally liable for the cost, which is a lot of money to come up with as a young working professional. And then, of course, she will be faced with the same scenario in a few months’ time.

When I asked her what her biggest frustration was when it came to dealing with insurance companies, she had this to say:

“The people that are working the customer service phones, who you have to call, have no idea how important these catheters are. Every time something gets denied, I personally have to sit on hold for HOURS to talk to a representative, who 9 times out of 10 is not able to help me because they don’t actually understand the medical supplies, they are simply just looking at billing codes.”

What To Do When Insurance Says No

If your healthcare claim has been rejected, know that you have options. If you are unsure where to start, I recommend taking a deep breath (or ten), reading this Forbes Advisor article, How To Appeal A Health Insurance Claim Denial written by Erik Martin, and remembering that when it comes to your health advocating for yourself is of the utmost importance.


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