When Insurance Stands in the Way of Your Healthcare

I am fortunate to have health insurance. I realize that’s a blessing and a privilege. Some years it’s been covered by an employer, other years, I paid out of pocket for it. So, while I know it comes at a premium cost, I am grateful for it.

Yet I continue to be baffled, and at times infuriated, that the very insurance that I pay for actually stands in the way of me receiving the care that my doctor is recommending.

This or That

Does insurance or the cost of medications get in the way of your migraine treatment?

How can insurance override my doctor’s recommendation? Let me take a step back to explain.

How did my doctor and I decide my treatment plan?

My doctor and I reviewed all the medication options for me and we decided on the one that best fit my symptoms and also factored in my health history to avoid any concerning side effects. I felt good walking away from the appointment because we dedicated my entire appointment just to making this one decision. It felt well thought out. I was so hopefully that I was going to get the relief that I needed.

Did my insurance company agree?

The relief was short-lived though. I was notified by the insurance company that they would not approve the medication. If I wanted a medication, I could receive the one that they recommended. Now, I like to believe that they have medical oversight on their decisions, however, they’re still blind recommendations not taking the patient – me – into account. They’re making a recommendation based on the best interest of their bottom line.

They said I could appeal it, but it would take time and the other patients that tried appeals didn’t have a high success rate. If I really wanted the prescription medication, then I had to pay out of pocket for it, which wasn’t sustainable.

Wasn't my doctor right though?

None of this made sense. My doctor has the medical training and has done all the evaluations on me, he is most qualified to know which medications are most appropriate for me and which ones will give me the most effective outcome.

How did my doctor respond?

When I called my doctor to let him know that insurance was only approving a different medication, he simply said, “Alene, I don’t disagree with you. The medication that I prescribed is the best medication for you, but the reality is I simply don’t have the time to fight with the insurance companies on this. It would consume all my time and I wouldn’t be able to see patients.”

Can I do anything about it?

He was right. If he had to go to bat for every single patient, he wouldn’t have the time to see patients. And perhaps insurance companies know this which is why they are getting away with having the upper hand. So what are we as patients supposed to do as we’re stuck in the middle of this mess? It’s our health that is taking the hit.

I wish I had an answer for you. And I don’t share this today to stoke a fire that I know many of you share with me as well. I share this more for validation that acknowledging that living with a chronic illness like migraine is hard enough, but to add on the red tape of insurance policies that prevent us from getting the relief we need, is just disheartening.

What have I done?

Honestly, what I have found most helpful in situations like this is to stick with the facts and not allow my emotions to overtake me. Yes, I’m frustrated and it feels like an injustice, but I have to look strictly at the facts and as frustrated as I may be with my insurance provider, I also know that the person on the other end of the phone didn’t make the policies. If I can appeal to that person to offer some guidance, that might be the breakthrough that I need.

I may ask, "Have you seen any other patients in a similar situation get approved for this medication?” or “Is there someone in the escalations department that may be able to assist me?” or “Are there any assistance programs that would enable me to receive the medication as a lower cost?”

What has worked for you? Have you found ways to navigate sticky situations like this?

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This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The Migraine.com team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

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