November 20, 2012
By Tamara E. Holmes, InsWeb.com
While the number of people who suffer from allergies is rising, many are finding that their health insurance don’t always provide adequate coverage. However, policyholders can fight back.
Many insurance plans limit policyholders’ access to care by allergy specialists because the plan providers believe that a primary care physician is equipped to handle the problem, says Allen Meadows, an allergist who serves on a health plan committee of the American Academy of Allergy Asthma & Immunology.
However, Meadows points out that primary care physicians aren’t as likely to be familiar with the latest research and treatment options for those suffering from allergies. Primary care physicians also may not diagnose those suffering with allergies correctly since they don’t see as many allergy cases as specialists.
“People who don’t see an allergist are at risk of having the allergy test misinterpreted,” Meadows says.
Another concern of allergy experts is that some insurance plans limit the types of allergy medications and treatments that are covered. For example, some plans don’t cover allergy shots.
When someone doesn’t receive the most effective treatment for allergies, he or she remains sick, Meadows says. “They may not be missing work, but they’re less productive because they feel so miserable,” he says.
People who don’t get proper treatment for allergies may also pay more in the long run, since they’ll likely make more visits to the doctor and can rack up co-pays and other charges, Meadows says.
Some plans also may not cover the entire cost of epinephrine autoinjectors, which are medical devices that are used to inject epinephrine – a shot of adrenaline that’s used to treat life-threatening allergic reactions. Such devices can cost $100 or more.
People who are being treated for allergies and related conditions such as allergy-induced asthma may be at a disadvantage when it comes to insurance companies charging higher premiums for those with pre-existing conditions, says Charlotte Collins, vice president for policy and programs at the Asthma and Allergy Foundation of America. While the federal health care reform law in 2014 will prevent insurers from denying coverage to consumers who have pre-existing conditions, there’s no law stopping insurers from charging people higher rates if they have certain conditions.
Another problem occurs sometimes when allergy patients switch jobs and in the process switch insurance plans. Sometimes insurers won’t cover the medication or course of treatment that the policyholder was using under the old plan, Collins says, so the consumer will end up having to switch medications even if a particular drug was working.
Ways to fight back
If you suffer from allergies and your insurance company refuses to pay for coverage of a particular treatment or doesn’t allow you to see an allergist, don’t immediately take “no” for an answer, experts say.
All insurance companies have an appeals process that lets you make your case about why a particular treatment or course of action should be covered.
If possible, have your physician help you by writing a letter that explains the medical justification for the treatment, Collins suggests. In some cases, insurers will deny coverage for newer drugs, labeling them as experimental. But if you can provide studies and other proof showing the effectiveness of the drug, you may be able to get your insurance company to reverse its decision.
When arguing your case, it might help to show how costly it is to treat allergic reactions if you don’t get your allergy under control. For example, a study by the Food Allergy & Anaphylaxis Network (FAAN) found that the average cost of an emergency room visit for a food allergic reaction was $533, while the average cost of a hospital stay for a food allergy reaction was $4,719.
Some people find it helpful to pay a couple hundred dollars out of their own pocket to see an allergist to get a diagnosis that they can take to their insurer as evidence that they need more treatment or specialized treatment, Meadows says. When policyholders are persistent, insurance companies eventually may prescribe specialized care.
“It’s generally the squeaky wheel that gets the oil,” Meadows says.
What are allergies?
Allergies are diseases that affect the immune system, with certain substances triggering a physical reaction. For example, a person who’s allergic to dust might sneeze or get the sniffles when he’s around dust mites.
Food allergies are particularly prevalent in the United States. About 15 million Americans have food allergies, according to FAAN. A study by the federal Centers for Disease Control and Prevention (CDC) found that the number of people diagnosed with food allergies rose about 18 percent between 1997 and 2007.
Yet food allergies aren’t the only concern. According to the CDC, 8 percent of U.S. adults have been diagnosed with hay fever or allergic rhinitis – nasal-related symptoms that occur when you inhale something that you’re allergic to, such as dust or pollen. Another 13 percent have been diagnosed with sinusitis, and 4 percent have chronic bronchitis. About 10 percent to 30 percent of the world’s population has allergic rhinitis, according to the American Academy of Allergy Asthma & Immunology.
Children are suffering, too:
• 13 percent have skin allergies.
• 12 percent suffer from respiratory allergies.
• 10 percent of U.S. children 17 and under have hay fever.
• 5 percent suffer from food allergies.