Vermont Legal Aid’s Health Care Ombudsman Convinces Insurance Company to Cover Pulmonary Rehabilitation
A woman with a severe, chronic lung condition called her insurance company and asked if they would cover a specialized pulmonary rehabilitation treatment she needed; the company said yes. She began therapy which significantly improved her medical condition and her quality of life. When her rehabilitation therapist submitted the claim, the insurance company denied coverage, saying they would not cover therapy for her particular lung condition. Vermont Legal Aid’s Health Care Ombudsman reviewed the certificate of coverage, the criteria for coverage and the medical evidence. Vermont Legal Aid helped its client appeal the denial and frame an argument for coverage; she won without having to go to external review. The insurance company agreed to cover the successful treatments.
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