Its all too common, an insurance provider denies a medically necessary claim and patients are forced to foot the bill, despite paying for medical insurance.
That's what almost happened to Jeremy and Lynda of Nanuet, if Senator David Carlucci had not got involved.
The couple's insurance provider denied a claim submitted by their son's doctor for coverage of a cranial helmet to correct the shape of James' skull.
According to the couple, the insurance company denied the claim four times, citing there was not enough medical documentation to warrant medical necessity.
However, as the family's doctor cited, the cranial helmet would help direct growth away from the flat spot.
"They were denying it for information that was actually further in the report so they were just kind of skimming through whatever they saw and deemed necessary to deny the claim and move on with it," said Jeremy, James' father.
Helmet therapy is not uncommon for infants with a condition called positional plagiocephaly. One study found 47% of babies ages 7 to 12 weeks had the condition, and 1 in 10 needed treatment.
Without medical insurance the helmet would cost the family almost $4,000 out of pocket as opposed to about $950. The family reached out to their State Senator, David Carlucci for help.
Carlucci stepped in right away and wrote a letter on the family's behalf, supporting the doctor's recommendation for the helmet and citing that it's medically necessary. The insurance company reviewed the case again and approved the claim.
"The push was there, it was less than a week, even though it seemed a lot longer for us. But it was overturned, we got the notification I think early on a Saturday, right before his scheduled appointment," said Jeremy, James' father.
Thankfully due to the Senator's letter, James was able to keep his appointment for the helmet fitting and was not delayed care. He had his new helmet in time for the Thanksgiving holiday.
"Definitely that much joyful and thankful for Senator Carlucci and just taking action and owning the problem and I really appreciate that," said Lynda, James' mother.
Lynda and James now want to remind others that when they have a problem, they should seek out their elected representatives for help.