Urgent Help Needed: Insurance Refusal to Pay for Rehabilitation After Ankle Fracture

Urgent Help Needed: Insurance Refusal to Pay for Rehabilitation After Ankle Fracture

Your friend and his wife are facing a difficult situation. His wife has an inoperable brain tumor that affects her balance and mobility. Recently, she broke her ankle and underwent surgery. She was sent to a rehabilitation facility, but insurance has stopped paying for her stay. This has left your friend in a bind as he cannot afford in-home help and has had to miss work to care for his wife.

Understanding Insurance Coverage for Rehabilitation

Insurance coverage for rehabilitation varies depending on the type of insurance plan and the specific circumstances of the patient. In general, rehabilitation is covered when it is considered medically necessary to help the patient regain function after an injury or illness. However, coverage may be limited in terms of the number of days or visits that are covered.

Reasons Why Insurance May Stop Paying for Rehabilitation

There are several reasons why insurance may stop paying for rehabilitation. These include:

Lack of progress: If the patient is not making sufficient progress in rehabilitation, the insurance company may determine that further rehabilitation is not medically necessary.

Exceeding coverage limits: Many insurance plans have limits on the number of days or visits that are covered for rehabilitation. Once these limits are reached, the insurance company may stop paying.

Change in medical orders: The patient’s doctor may change the orders to discontinue rehabilitation and transition to a different type of care, such as in-home therapy or independent exercises.

Plateau in improvement: The patient may have reached a plateau in their improvement and further rehabilitation is unlikely to result in significant additional gains.

What to Do When Insurance Refuses to Pay

If insurance has stopped paying for rehabilitation, there are several steps you can take:

Review your policy: Carefully review your insurance policy to understand the coverage details and any limitations on rehabilitation.

Contact your insurance company: Call your insurance company to inquire why coverage has been stopped. They should be able to provide you with specific reasons.

Appeal the decision: If you believe that the insurance company’s decision is incorrect, you can file an appeal. You will need to provide documentation to support your claim that further rehabilitation is medically necessary.

Explore other coverage options: If your insurance plan does not cover rehabilitation, you may be able to qualify for coverage under Medicaid or other government programs.

Consider personal insurance: There are personal insurance plans available through the Affordable Care Act (ACA) that may provide coverage for rehabilitation.

Your friend should also consider consulting with a lawyer who specializes in health insurance law. They can help him understand his rights and provide guidance on how to proceed.

It is important to remember that insurance companies are businesses that make decisions based on their financial interests. However, you have the right to appeal their decisions and explore other coverage options. By taking proactive steps, you can help your friend get the care he needs.