Fighting for Coverage: How I Learned to Navigate the Appeals Process
December 12, 2017

By Rocky Schwartz, Guest Blogger

As a woman in long-term recovery from alcoholism and addiction for 35 years, I have been quietly involved in the recovery community for several decades. I naively believed that I would be able to prevent my children from suffering from addiction. But sadly, that hasn’t been the case.

Both of my sons have struggling with mental health and addiction issues for the past seven years. At the age of 18, my oldest son experienced a sudden, severe psychotic break. I felt as if our family had been struck by a hurricane or tornado. I was completely unprepared for and baffled by our “new normal.” It was then that I realized just how broken our country’s mental health system is, and that insurers were blatantly ignoring the Federal Parity Law. I had to charge $1000 per day to our credit card to keep our son in a highly-regarded psychiatric facility. Meanwhile, my younger son was diving deeper and deeper into addiction.

I paid out of pocket because I had to act fast to save our son’s life. Like others in this situation, I planned to file an appeal to the insurance company and be reimbursed afterward. $300,000 and seven years later, I have lost six insurance appeals with two different insurance companies. Pursuing these claims was exhausting. I gave up on the first few appeals due to emotional fatigue. With each insurance denial, I became more and more outraged. Finally, I decided enough was enough – I could not allow this to happen anymore.

The process of filing appeals is painstaking. It requires exemplary organizational skills. There are voluminous amounts of paperwork involved, and most people have to sort through hundreds of pages of medical records. The insurance companies provide no guidance whatsoever. At my wits’ end and looking for help, I discovered The Kennedy Forum’s Parity Registry online. Finally, I thought – serious tools to help guide me in this confusing process. I was happy to see sample appeal letters for insurance companies, and even sample advocacy letters for members of Congress. The website outlined specific steps for the appeal process. It also lets you register for insurance denials so that more data can be collected – to prove that parity violations still exist.

Through The Kennedy Forum, I learned about the New Jersey Parity Coalition, where I ultimately met other family members in the same situation as me. Through this coalition, providers and policy professionals that are trying to improve adherence to the Federal Parity Law in our state.

Appealing an insurance claim is complicated, and there are so many ways to get lost in the process. For example, before finding the Parity Registry, I thought only my state’s Department of Banking and Insurance could help me. The Parity Registry actually explained that I have an employer-sponsored plan that falls under the Employee Retirement Income Security Act (ERISA), and should therefore be enforced by the U.S. Department of Labor (DOL). After finally filing an appeal with the correct agency, I am currently waiting on a decision from the DOL.

I am NOT giving up this time. I am hopeful that my current appeal will be overturned and I will be reimbursed for the residential care that one of my sons needed 18 months ago. He was court-ordered to treatment by a judge. My insurance company quit paying for his treatment on a certain date, even though the clinical staff at the facility clearly stated (in the medical record) that he could not be safely discharged at that time. I believe he is only alive today because of the medical care we paid for out of pocket.

I am truly grateful for the Parity Registry website, and for Patrick Kennedy’s advocacy. I am looking forward to a day when there is true parity in our health care system and when other families will not have to suffer the financial and emotional toll that we have.