Wednesday, 16 July 2014

Ways of claiming a Health Care Card

Ways of claiming a Health Care Card

You can make a claim for some of the Health Care Cards on line or by filling in the appropriate forms.

Claiming on line

An online claim option is available for the Low Income Health Care Card, Foster Child Health Care Card and Ex-Carer Allowance (child) Health Care Card.
If you wish to claim on line, you should register for an online account and then log on to claim the appropriate Health Care Card.

Claiming with forms

To claim a card using a paper claim form you can:

Documentation

When lodging your claim, we will ask you for information to assess your entitlement. This includes your and your partner's income and assets.
Once you submit your claim you will need to provide proof of identity. We will also tell you if there are other documents and forms you need to provide. You will need to submit these within 14 days. The sooner we receive your documents, the sooner we can process your claim.

Claim outcome

We will send you a letter advising whether your claim has been successful.
If your claim is successful, we will send your Health Care Card in the mail.

If you disagree with a decision we make

You always have the right to appeal any decision made by us. See information on Reviews and appeals.

Claiming the Low Income Health Care Card

Before you start

Check if you are eligible for this payment before you start your claim.
You should register an intent to claim for a Low Income Health Care Card. This will help you get your card from the earliest possible date.

Claiming options

Online

A secure, convenient and easy way to start a claim for a Low Income Health Care Card. Once you have completed your claim online, bring the supporting documents requested on the claim form to a service centre within 14 days.
If you already have online access to your Centrelink account, you can log on with your Customer Reference Number (CRN) and password. Select Apply for a Payment thenMake a Claim from the menu to start your claim.

Claim forms

Print and complete a Claim for a Health Care Card form.

Supporting documentation

You may need to complete some additional forms with the claim form. This will help us assess your claim accurately, based on your personal circumstances. Additional forms and documents you may need to provide include:
  • proof of identity for yourself and your partner
  • proof of your adjusted taxable income for yourself and your partner, or
  • any other verification documents we request

Submit your claim

If you completed your claim online you will need to provide us with your supporting documentation within 14 days.
If you are claiming in person, submit your claim and supporting documentation to your nearestservice centre. We will need these documents before we can finalise your Low Income Health Care Card claim.

Claim outcome

If your claim is successful, we will send your Low Income Health Care Card in the mail. 
You always have the right to appeal any decision we make. Read more about reviews and appeals.



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How to boost your immune system and stay healthy

How to boost your immune system

Excerpted from The Truth About Your Immune System, a Special Health Report from Harvard Health Publications

What can you do?

On the whole, your immune system does a remarkable job of defending you against disease-causing microorganisms. But sometimes it fails: A germ invades successfully and makes you sick. Is it possible to intervene in this process and make your immune system stronger? What if you improve your diet? Take certain vitamins or herbal preparations? Make other lifestyle changes in the hope of producing a near-perfect immune response?
The idea of boosting your immunity is enticing, but the ability to do so has proved elusive for several reasons. The immune system is precisely that — a system, not a single entity. To function well, it requires balance and harmony. There is still much that researchers don’t know about the intricacies and interconnectedness of the immune response. For now, there are no scientifically proven direct links between lifestyle and enhanced immune function.
But that doesn’t mean the effects of lifestyle on the immune system aren’t intriguing and shouldn’t be studied. Quite a number of researchers are exploring the effects of diet, exercise, age, psychological stress, herbal supplements, and other factors on the immune response, both in animals and in humans. Although interesting results are emerging, thus far they can only be considered preliminary. That’s because researchers are still trying to understand how the immune system works and how to interpret measurements of immune function. The following sections summarize some of the most active areas of research into these topics. In the meantime, general healthy-living strategies are a good way to start giving your immune system the upper hand.
Immunity in action
Immunity in action. A healthy immune system can defeat invading pathogens as shown above, where two bacteria that cause gonorrhea are no match for the large phagocyte, called a neutrophil, that engulfs and kills them (see arrows).
Photos courtesy of Michael N. Starnbach, Ph.D., Harvard Medical School

Adopt healthy-living strategies

Your first line of defense is to choose a healthy lifestyle. Following general good-health guidelines is the single best step you can take toward keeping your immune system strong and healthy. Every part of your body, including your immune system, functions better when protected from environmental assaults and bolstered by healthy-living strategies such as these:
  • Don’t smoke.
  • Eat a diet high in fruits, vegetables, and whole grains, and low in saturated fat.
  • Exercise regularly.
  • Maintain a healthy weight.
  • Control your blood pressure.
  • If you drink alcohol, drink only in moderation.
  • Get adequate sleep.
  • Take steps to avoid infection, such as washing your hands frequently and cooking meats thoroughly.
  • Get regular medical screening tests for people in your age group and risk category.

Be skeptical

Many products on store shelves claim to boost or support immunity. But the concept of boosting immunity actually makes little sense scientifically. In fact, boosting the number of cells in your body — immune cells or others — is not necessarily a good thing. For example, athletes who engage in “blood doping” — pumping blood into their systems to boost their number of blood cells and enhance their performance — run the risk of strokes.
Attempting to boost the cells of the immune system is especially complicated because there are so many different kinds of cells in the immune system that respond to so many different microbes in so many ways. Which cells should you boost, and to what number? So far, scientists do not know the answer. What is known is that the body is continually generating immune cells. Certainly it produces many more lymphocytes than it can possibly use. The extra cells remove themselves through a natural process of cell death called apoptosis — some before they see any action, some after the battle is won. No one knows how many cells or what kinds of cells the immune system needs to function at its optimum level.
Scientists do know more about the low end of the scale. When the number of T cells in an HIV/AIDS patient drops below a certain level, the patient gets sick because the immune system doesn’t have enough T cells to fight off infection. So there is a bottom number below which the immune system can’t do its job. But how many T cells is comfortably enough, and beyond that point, is more better? We don’t know.
Many researchers are trying to explore the effects of a variety of factors — from foods and herbal supplements to exercise and stress — on immunity. Some take measures of certain blood components like lymphocytes or cytokines. But thus far, no one really knows what these measurements mean in terms of your body’s ability to fight disease. They provide a way of detecting whether something is going on, but science isn’t yet sufficiently advanced to understand how this translates into success in warding off disease.
A different scientific approach looks at the effect of certain lifestyle modifications on the incidence of disease. If a study shows significantly less disease, researchers consider whether the immune system is being strengthened in some way. Based on these studies, there is now evidence that even though we may not be able to prove a direct link between a certain lifestyle and an improved immune response, we can at least show that some links are likely.

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Organic foods: Are they safer? More nutritious? claim!

Organic foods: Are they safer? More nutritious?

Discover the real difference between organic foods and their traditionally grown counterparts when it comes to nutrition, safety and price.
By Mayo Clinic Staff
Once found only in health food stores, organic food is now a regular feature at most supermarkets. And that's created a bit of a dilemma in the produce aisle.
On one hand, you have a conventionally grown apple. On the other, you have one that's organic. Both apples are firm, shiny and red. Both provide vitamins and fiber, and both are free of fat, sodium and cholesterol. Which should you choose? Get the facts before you shop.

Conventional vs. organic farming

The word "organic" refers to the way farmers grow and process agricultural products, such as fruits, vegetables, grains, dairy products and meat. Organic farming practices are designed to encourage soil and water conservation and reduce pollution.
Farmers who grow organic produce don't use conventional methods to fertilize and control weeds. Examples of organic farming practices include using natural fertilizers to feed soil and plants, and using crop rotation or mulch to manage weeds.

Organic or not? Check the label

The U.S. Department of Agriculture (USDA) has established an organic 
certification program
 that requires all organic foods to meet strict government standards. These standards regulate how such foods are grown, handled and processed.

Any product labeled as organic must be USDA certified. Only producers who sell less than $5,000 a year in organic foods are exempt from this certification; however, they're still required to follow the USDA's standards for organic foods.
If a food bears a USDA Organic label, it means it's produced and processed according to the USDA standards. The seal is voluntary, but many organic producers use it.
Illustration of the USDA organic seal
Products certified 95 percent or more organic may display this USDA seal.
Products that are completely organic — such as fruits, vegetables, eggs or other single-ingredient foods — are labeled 100 percent organic and can carry the USDA seal.
Foods that have more than one ingredient, such as breakfast cereal, can use the USDA organic seal plus the following wording, depending on the number of organic ingredients:
  • 100 percent organic. To use this phrase, products must be either completely organic or made of all organic ingredients.
  • Organic. Products must be at least 95 percent organic to use this term.
Products that contain at least 70 percent organic ingredients may say "made with organic ingredients" on the label, but may not use the seal. Foods containing less than 70 percent organic ingredients can't use the seal or the word "organic" on their product labels. They can include the organic items in their ingredient list, however.

Do 'organic' and 'natural' mean the same thing?

No, "natural" and "organic" are not interchangeable terms. You may see "natural" and other terms such as "all natural," "free-range" or "hormone-free" on food labels. These descriptions must be truthful, but don't confuse them with the term "organic." Only foods that are grown and processed according to USDA organic standards can be labeled organic.

The Truth About Coconut Oil

http://claim789.blogspot.com/2014/07/how-to-boost-your-immune-system-and.html

The Truth About Coconut Oil

Coconut oil, according to recent reports, is the latest food cure-all. Claims abound that coconut oil is a health food that can cure everything from poor immune function,thyroid disease, and heart disease, to obesitycancer, and HIV.  
So should you stock up on coconut oil? Not so fast.
The evidence that coconut oil is super-healthful is not convincing and these claims appear to be more testimonials than clinical evidence.
There is very limited evidence on disease outcomes, says Dariush Mozaffarian, MD, DrPH, of Harvard Medical School and Harvard School of Public Health. "All that has been studied well is the impact of coconut oil on cholesterol levels and the findings are intriguing but we still don't know if it is harmful or beneficial," Mozaffarian says.
Neither the American Heart Association (AHA) nor the U.S. government's 2010 Dietary Guidelines suggest that coconut oil is any better or preferable over other saturated fats. Coconut oil, like all saturated fats, should be limited to 7%-10% of calories because it can increase risk for heart disease, according to the AHA and 2010 Dietary Guidelines.

What Is Coconut Oil?

Pure virgin coconut oil, containing no hydrogenation (the process of adding hydrogen to make a liquid fat hard), contains 92% saturated fat -- the highest amount of saturated fat of any fat.
Most saturated fats are solid at room temperature, found in animal products (such as meat, dairy, poultry with skin, and beef fat) and contain cholesterol. Unlike animal fats, tropical oils -- palm, palm kernel, and coconut oils -- are saturated fats that are called oils but depending on room temperature can be solid, semi-solid, or liquid, and do not contain cholesterol.
Like all fats, coconut oil is a blend of fatty acids. Coconut oil contains an unusual blend of short and medium chain fatty acids, primarily lauric (44%) and myristic (16.8%) acids. It is this unusual composition that may offer some health benefits.
Additionally, "because they come from coconuts, they may contain beneficial plant chemicals that have yet to be discovered," says Mozaffarian, researcher and co-director of the cardiovascular epidemiology program at Harvard.
As for calories, all fats have the same number of calories per gram. One tablespoon of coconut oils contains 117 calories, 14 grams fat, 12 g saturated fat, and no vitamins or minerals.
A pint of extra virgin coconut oils costs from $12-$18.

Is Coconut Oil Better Than Other Fats and Oils?

"Coconut oil is better than butter and trans fats but not as good as liquid vegetable oils," says Penn State University cardiovascular nutrition researcher Penny Kris-Etherton, PhD, RD.
Mozaffarian agrees that coconut oil is better than partially hydrogenated trans fats and possibly animal fats.
"But even though coconut oil is cholesterol-free, it is still a saturated fat that needs to be limited in the diet and if you are looking for real health benefits, switch from saturated fats to unsaturated fats by using vegetable oils like soybean, canola, corn, or olive oil," says Kris-Etherton, a member of the 2005 Dietary Guidelines advisory committee and Institute of Medicine's panel on dietary reference intakes for macronutrients (which include fats).


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Inova Health Foundation


Ways to Give

Charitable giving helps us provide the margin of excellence you have come to expect in your community hospital. Gifts to Inova, which are governed by volunteer trustees who are members of our community, are gifts to a community-based, not-for-profit healthcare provider that puts the health of our community as its number one priority.

Honoring your generosity

We are grateful for your support and are pleased to recognize your gift in many ways such as inclusion in our Annual Honor Roll of Donors. Friends who make an annual gift of $1,000 or more become members of our Founders' Circle societies. As a Founders' Circle member, your name will be listed on a donor wall in the lobby of the hospital or program facility to which your gift is designated. You will also be invited to selected events and will receive special updates from Inova Health Foundation.
Individuals who have made a generous gift to help build the Inova Comprehensive Cancer and Research Institute – a regional leader in the diagnosis and treatment of cancer – are honored on ourICCRI Honor Roll. We are grateful for their commitment to our lifesaving mission.
Another way to memorialize your family or a loved one is through a naming opportunity at one of our Inova facilities located throughout Northern Virginia. Please contact us to discuss your specific areas of interest or to determine how you and our hospitals can achieve maximum benefit.
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This cynical five-a-day myth: Nutrition expert claims we've all been duped

With great fanfare, it was reported last week that the current health advice about eating five portions of fruit and vegetables a day is outdated, and that scientists now believe that eight portions is more beneficial.
While many people grumbled about how on earth they would manage those extra portions, I ­allowed myself a wry smile.
For more than two years I’ve known that the ‘five-a-day’ mantra we’re all so familiar with is nothing but a fairytale.
Myth: The truth is that fruit and veg are pretty useless nutritionally
Myth: The truth is that fruit and veg are pretty useless nutritionally
Of course, they are tasty, colourful additions to any meal. But in terms of health and nutrition, fruit and veg have little to offer, and telling us to eat eight portions a day is compounding one of the worst health fallacies in recent history.
Surprised? Many people will be, and no doubt some dieticians and nutritionists will reject my arguments. But science backs me up.
The latest findings come from a European study into diet and health looking at 300,000 people in eight countries.
It found that people who ate eight or more portions of fresh food a day had a 22 per cent lower chance of dying from heart disease. Yet just 1,636 participants died during the study from heart disease, which is about half of one per cent.
Out of that very small proportion, fewer people died from the group that ate more fruit and veg.
However, the researchers cautioned that these people may have healthier lifestyles generally. They may be less likely to smoke; they may eat less processed food; they may be more active.
What we should not do is to make the usual bad science leap from association to causation and say ‘eating more fruit and veg lowers the risk of dying from heart disease’.
Vegetables offer some vitamins, but your body will be able to absorb these only if you add some fat, such as butter or olive oil
This survey comes not long after another large study, which examined half a million people over eight years, reported that fruit and veg offer no protection against breast, prostate, bowel, lung or any other kind of tumour. Those eating the most fruit and veg showed no difference in cancer risk compared with those ­eating the least.
So how have we been duped for so long?
You might assume our five-a-day ­fixation is based on firm evidence. But you’d be wrong.
It started as a marketing campaign dreamt up by around 20 fruit and veg ­companies and the U.S. National Cancer Institute at a meeting in California in 1991. And it’s been remarkably successful.
People in 25 countries, across three continents, have been urged to eat more greens, and have done so in their millions, believing it was good for them.
No doubt it was set up with the best intentions — to improve the health of the nation and reduce the incidence of cancer. But there was no evidence that it was doing us any good at all.
The fact that our own government has spent £3.3 million over the past four years on the five-a-day message shows how pervasive this belief is.
People are convinced that fruit and vegetables are a particularly good source of vitamins and minerals.
Andrew Lansley: Said that only three in ten adults eat the recommended five-a-day
Andrew Lansley: Said that only three in ten adults eat the recommended five-a-day
For a long time, I too was a believer. I was a vegetarian for 20 years. It is only after nearly two decades of my own research — I am a Cambridge graduate and currently studying for a PhD in nutrition —that I have changed my views.
The message that fruit and veg are pretty useless, nutritionally, gradually dawned on me.
The facts are these. There are 13 vitamins and fruit is good for one of them, vitamin C.
Vegetables offer some vitamins — vitamin C and the vegetable form of the fat-soluble vitamins A and vitamin K1 — but your body will be able to absorb these only if you add some fat, such as butter or olive oil.
The useful forms of A and K — ­retinol and K2 respectively — are found only in animal foods. As for minerals, there are 16 and fruit is good for one of them, potassium, which is not a substance we are often short of, as it is found in water.
Vegetables can be OK for iron and calcium but the vitamins and minerals in animal foods (meat, fish, eggs and dairy products) beat those in fruit and vegetables hands down. There is far more vitamin A in liver than in an apple, for instance.
But surely, people ask, even if there is no evidence that increasing our intake of fruit and vegetables will help prevent disease, they remain good things to eat?
I don’t think so. If people try to add five portions of fruit and veg — let alone eight — a day to their diet, it can be counterproductive. Fruit contains high levels of fructose, or fruit sugar.
Among dieticians, fructose is known as ‘the fattening carbohydrate’. It is not metabolised by the body in the same way as glucose, which enters the bloodstream and has a chance to be used for energy before it heads to the liver.
Fructose goes straight to the liver and is stored as fat. Very few ­people understand or want to believe this biochemical fact.
Another argument that is often put forward by dieticians on behalf of fruit and vegetables is that they are ‘a source of antioxidants’.
They believe we need to have more ­antioxidants in our diet to counteract the oxidants that damage the body’s cells, either as a result of normal metabolic processes or as a reaction to environmental chemicals and pollutants.
But I would rather concentrate on not putting oxidants such as sugar, processed food, cigarette smoke or chemicals into my body.
Good to eat: But five a day is not necessarily helpful
Good to eat: But five a day is not necessarily helpful
Besides, fruit has a fraction of the antioxidants of coffee, though you rarely hear dieticians singing ­coffee’s praises.
Incidentally, the body’s ­natural antioxidant is vitamin E, which is found in seeds — and ­particularly sunflower seeds.
Another problem is that dieticians tell you to eat less fat. We’re told that fat is bad for us but this has not been proven at all.
Of course, man-made trans-fats such as those found in biscuits and cakes are very unhealthy and should be banned.
But natural fats such as those in eggs, meat and fish should not be demonised alongside trans-fats. They are essential to our wellbeing and they are what we’ve lived on for thousands of years.
According to a recent survey, the British people are deficient in ­vitamins A, D, E — all of which are fat-soluble. If we added a dollop of butter to our portion of vegetables, they would be better for us — not worse.
Essential minerals are absorbed while food is in the intestines, so why do we want to flush everything out? It is far better to concentrate on not putting bad foods into your body
Then there is the issue of fibre. Again, I don’t agree with the ­prevailing view that we should all eat more fibre in order to help us feel full and keep our digestive systems moving. 
The fact is, we can’t digest fibre. How can something we can’t even digest be so important to us, nutritionally?
We are told that we need to ‘flush out’ our digestive systems. But essential minerals are absorbed while food is in the intestines, so why do we want to flush everything out? It is far better to concentrate on not putting bad foods into your body.
The biggest tragedy of all is the lost opportunity from this misguided five-a-day campaign.
If only we had hand-picked the five foodstuffs that are actually most nutritious and spent what the Department of Health has spent on promoting fruit and vegetables over the past 20 years on recommending them, we could have made an ­enormous difference to the health and weight of our nation.
If you ask me, these foodstuffs are liver (good for all vitamins and packed with minerals), sardines (for vitamin D and calcium), eggs (all-round super-food with vitamins A, B, D, E and K, iron, zinc, calcium and more), sunflower seeds (magnesium, vitamin E and zinc) and dark-green vegetables such as broccoli or spinach (for vitamins C, K and iron).
Add milk (good for calcium, vitamins A and D), porridge oats (magnesium, zinc and B vitamins) and cocoa powder (magnesium and iron) and, hey presto, you’re provided with the full quota of every vitamin and mineral our bodies need.
In a long-awaited Public Health White Paper late last year, Health Secretary Andrew Lansley said that only three in ten adults eat the ­recommended five-a-day.
Later in the same document, he asks how can we improve the use of evidence in public health. My suggestion is that he gets his own facts on five-a-day straight and saves himself the bother of worrying about fruit and veg.
 http://claim789.blogspot.com/2014/07/how-to-boost-your-immune-system-and.html


Read more: http://www.dailymail.co.uk/femail/food/article-1349960/5-day-fruit-vegetables-myth-claims-nutrition-expert.html#ixzz37eSyA3uR
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Types of salt and their effect on health

Sea salt and rock salt

Gourmet rock and sea salts have been popularised by TV chefs who sprinkle them liberally on their culinary creations. Due to their premium image and the misleading  claims of manufacturers declaring that their product is ‘natural’, contains ‘essential minerals’, and is a ‘tastier and healthier alternative’ to table salt, there is a popular belief that these salts are better for us. A recent Which? survey reveals that more than one in four Which? (28%) members think rock and sea salts are healthier than table salt.It is understood that many people are switching to more expensive and premium forms of salt, such as sea salt and rock salt, because they believe that they are healthier than table salt. In fact one survey has shown that 61% of consumers believe that sea salt is lower in sodium than table salt. Garlic salt and celery salt are also popular alternatives to standard table salt. Companies and chefs often highlight the fact that sea salt has been used in a food with the implication that it makes it a tastier and more natural product.
Do not be deceived! Salt is salt. No matter how expensive salt is, whether it comes in crystals or grains, from the sea or from the Himalayas, a new CASH survey has found they all contain an equally high sodium chloride content as table and cooking salt. Sodium and chloride combine to form salt (NaCl), it is this combination of minerals which puts up our blood pressure, leading to strokes, heart failure and heart disease. Aside from certain alternatives to sodium salts such as Potassium salt (see below), all salts are equally damaging to our health, don’t be fooled by the claims made by salt manufacturers.
Garlic salt and celery salt are also popular alternatives to standard table salt. These products are made predominantly of table, rock or sea salt combined with small amounts of dried garlic or celery. The salt component is still sodium chloride so these too should be limited as with rock and sea salt.

Potassium salt

Salts which contain a combination of sodium and potassium chloride are now widely available in the UK. The most widely available and used product is Lo Salt.
Potassium salts have up to 70% less sodium than standard table salt so do not carry the same high risks as sodium based salts. Potassium salts may even have a beneficial effect on your blood pressure because potassium is an antagonist of sodium.
Potassium salts can be used in the same way as standard table salt and many people feel they do replace their need for salt. However, other people have reported a metallic after taste and therefore choose not to use them. Another problem with using potassium salts is that, although you have less sodium, you still have salty tasting foods and therefore your preferences for salt is not changed.
People with kidney disease or diabetes should seek medical advice before using potassium salts, as an increase in potassium intake may not be advisable.
Taste-test study
A study from Ireland demonstrated that lasagne produced with reduced salt levels and potassium salt scored higher for taste than the ‘normal’ salt version. The lower salt lasagna had nearly 30% less salt than the normal lasagne, without affecting the overall taste and saltiness of the finished product

Iodised Salt

CASH acknowledges that iodine deficiency is a potentially serious problem in the UK, particularly in teenage girls and in unplanned pregnancies. However, we are concerned about the public health implication of using iodized table salt as the solution.
Using table salt as a vehicle for carrying iodine is, in our view, not sensible as it requires us to put something that is potentially good into something that is known to be bad for our health. We feel that, given the high intake of salt we have in the UK and the progress that is being made, making salt beneficial to our diet is a conflict in public health. If people are aware of their need to increase iodine consumption we do not want them to think that increasing their intake of table salt is the answer. More than anything this is a confusing message for consumers. 

Adjusting to lower salt foods

Reducing the amount of salt in your food (without the use of salty tasting substitutes) is the preferable way that you can improve your health, although it can take awhile as foods may initially taste bland. However, within two or three weeks you will become accustomed to the taste of lower salt foods. During this time the salt taste receptors in the mouth become much more sensitive to salt and you will begin to detect a salty taste in anything which you previously ate. Using other sources of flavour, such as herbs, spices, black pepper, vinegar, lemon juice and chilli can improve completely the taste of food to make the transition even easier for you. Once the salt taste receptors have adjusted, you will find that high salt foods will taste unpleasant. The same applies to fatty and sugary foods.

Salt reduction in processed foods

There is a currently a huge amount of pressure on the food industry to reduce the salt content of the processed foods that they sell. A lot of research is going into finding ways that salt can be reduced in foods without affecting any of the sensory characteristics such as taste and texture. The solutions to date range from simply using potassium salt to using micro fine salt crystals which, even when a small amount is used, can give an intense salty flavour. Flavour enhancers have also been explored as a way of increasing salty taste so that the salt level can be reduced.

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when your health insurance company denies your claim

Tips on what to do when your health insurance company denies your claim

I get asked a lot about health insurance claims. Having had many different diagnoses, surgeries, and procedures I have became all too familiar with interacting with insurance companies. In the last few years my diagnosis of breast cancer and the almost simultaneous diagnosis of our son Tristan with congenital spine and hand abnormalities has meant a level of paperwork, claims, and appeals I could never have imagined.
Navigating the maze of medical care and health insurance has become second nature to me. I think I’ve resisted writing this piece because initially I thought there wasn’t much to say. Having worked on this piece for weeks now, I realize the opposite is true: there is too much to say. Because each case is different it’s very hard to offer advice on what you, the reader, should do. But I’ve decided that’s the beauty of the blog format: I don’t have to cover all the bases. I don’t have to have all of the answers. I just need to do my best to help. And so today I’m starting to tackle this beast.
I’ve had many requests to write pieces about how to win against health insurance companies and many have suggested I go into this as a profession. I’m not sure about that one but I am definitely willing to share some of the insights I’ve learned throughout the past few years. I do think my upbringing in a medical household (my father was a cardiothoracic surgeon) helped familiarize me with medical terminology and how to correctly present a medical history.1 In addition to my tips you may be interested to read Wendell Potter’s recent advice in The New York Times: “A Health Insurance Insider Offers Words of Advice.”
Don’t take ‘no’ for an answer
The first piece of advice I have is simple: don’t take no for an answer. The fact your claim was denied is the starting point not the ending point. Insurance companies count on the fact that a large percentage of subscribers will receive a denial and either 1) forget about it, 2) intend to file an appeal but not follow through, or 3) incorrectly file the appeal paperwork (see Potter’s article, above). In any case, if they send you a claim denial and you don’t follow up for any reason, they win.
Always appeal
If you receive a rejection to a claim you feel you are entitled to always appeal. When I receive a claim denial I roll my eyes, roll up my sleeves, and say, “here we go again.” It’s what I expect, but it’s never the last word to me. Now, that is not to say that you always win– but it would take way more than one denial for me to accept that I’m not entitled to have a medical service covered. Persistence and determination are a large part of what it takes to win.
Physical (especially congenital) problems are easier to appeal than those related to developmental delays. I have little/no experience with appeals for diagnoses related solely to delays; while many of my general tips will still apply, more specific ideas will hopefully be available elsewhere online for those types of claims. I do know that when it comes to dealing with insurance companies those types of diagnoses are harder to quantify; this often leads to greater challenges with insurance appeals. In my experience, if the delays can be linked to anatomical problems, orthopedic issues, or diagnoses that can be validated with tests like MRIs or CTs, the case will be easier to justify.
Insurance companies must give you a reason whey they are denying a claim. Most often this reason is that 1) the treatment is experimental or investigational, 2) the treatment is not medically necessary, or 3) the treatment is not the standard of care.
In our case, initial denials have most often been because it wasn’t considered medically necessary.2
Show the progression of the situation and how options have been exhausted
I always try to base appeals on the phrases “medical necessity” and “medically necessary.” When you document a surgery or service that you or your familymember needs:
Be clear how it is necessary to daily functioning.
Describe what will happen if what you are asking for doesn’t happen.
Be sure to tell what you have tried already, and what has failed.
Show how your diagnosis and treatment history has brought you to this place–how there is no other reasonable option to what you are asking for (or how the alternative is not preferable).
Be complete but don’t ramble.
Be sure to include diagnosis codes and treatment codes (your medical professionalwill provide these).
Doctors’ offices don’t always have the final say
I should point out that a doctor’s office may tell you that you will have to pay out-of-pocket. They may tell you that they have tried to get your service covered, it was denied and therefore this is the last word. It’s not. For example, my neurologist’s office tried to get my Botox injections covered. Their office appealed the first rejection. They were again denied. They told me that there was “nothing else they could do”; I would have to pay.
Undeterred, I asked for copies of my medical records. I called my insurance company and asked what I needed to do. Despite what the doctor’s office told me, I learned that patients often have a separate appeals process available to them. While physicians’ offices can often get services covered and can be very helpful in knowing what’s been a successful method of appeal in the past, they are not the only way to get services approved. In a case like this there is actually a financial disincentive for them to have insurance cover it; therefore, they may not be as aggressive as you will. What does that mean? If I had paid out of pocket they would have received almost three times the amount of money that they receive when compensated by my insurance company directly.
When the office tried to get the injections covered, the insurance company denied the request on the basis that this was an experimental treatment– not FDA-approved for this use. I provided medical history sheets from my medical file. I documented every drug I had take until that point to try to prevent migraines and the dates I took them. I explained the medical condition/situation that resulted when I had migraines. I told them how the neurologist felt the Botox might help me. I included the original letter he had written to the insurance company. I explained that if they didn’t cover this treatment a more expensive, more medically damaging situation would result– this would mean more claims and more expense for the company. In the case of the migraines I documented how much my “rescue medications” were costing them per month and how a reduction in those would easily pay for the Botox I was asking for. I showed through my history with the numerous failed attempts with other drugs that the situation had not improved and in fact the side effects from those drugs had been debilitating. I also showed the 
literature
 about preliminary success in clinical trials with Botox and my neurologist’s observations about its efficacy in others and the potential efficacy in my case. I explained I had no other choice, and while it might be not-yet FDA approved, Botox was actually on the verge of receiving such approval (I was proved right when it did receive approval for this purpose less than one year after my request).
Include all relevant information and send appeal within the required time period
This letter of appeal doesn’t need to be 3 pages long. In fact, even in my most complicated appeals I didn’t write more than a page or two at most (plus the inclusion of the supporting documents). Be sure to appeal/respond within the time frame they dictate. In the letter be sure to include:
your contact information, subscriber number, and the doctor/hospital/treatment facility information
the case reference number that they provide
all relevant diagnosis and procedure codes
Ask doctors and staff for assistance, documents
Do not be afraid to ask your doctor and his/her staff for help: what tactics have they found useful? If there are multiple codes that apply which ones are the best to use? Do they have any sample letters for appealing? What has their experience been with your particular health insurance company?
Use the rejection letter as the foundation for your appeal
Take the rejection letter you received and read it carefully. Don’t just react with “it says no” and throw it away. It is vital; in it, the company must tell you why they are rejecting your claim (usually one of those three reasons I mentioned at the outset).This is the key to your appeal. You must address this issue. They’re telling you the basis, you need to fight based on that. Be thorough but don’t get off track.
Another good example of persistence in appeals came with a corrective band we used for Tristan’s quite-misshapen head (diagnoses of plagiocephaly and brachiocephaly). The facility we used for the DOC band told us that insurance claims were most often denied for this service. Indeed, the first claim was denied; they said the “helmet” to correct his misshapen head was for cosmetic reasons only. I appealed. I explained that because of his neck abnormalities the head deformity was an inevitable result of having his head fixed in one place. Because he was unable to move his head properly he had this inevitable result of a physical abnormality. I ended up having two helmets approved for coverage.3 Had I accepted the facility’s statement that “insurance companies usually don’t pay for this” or my first rejection letter from the company, we would have had to pay in full for both helmets. I should point out that I’ve seen success getting this particular service covered even when the plagiocephaly was not due to a unique condition like Tristan’s when the subscriber persisted with the appeal process.
You can appeal more than just a denied claim
- A facility that isn’t usually in-network may actually be considered in-network for some diagnoses. For example, Memorial Sloan Kettering Hospital in New York City is a hospital that specializes in treatment of cancer. Though it isn’t normally included in coverage by some health plans, insurance companies will often allow oncology treatments there under the Centers of Excellence program. Through this policy, hospitals that specialize in certain conditions are treated as participating centers (in-network). So, if you wish to have medical care at a facility that specializes in a certain medical condition be sure to check whether they are included in this special program.
-Prescription drug plans can be adapted. This is a big one. What do I mean by this? Just because your prescription drug plan says it will only cover a certain number of pills doesnt mean that’s the last word. My prescription drug plan said only 9 pills of my expensive migraine medication would be covered each month. The problem? I frequently needed more than that number. I decided to investigate. I called my insurance company and the administrators of the prescription plan and asked how I could get that number increased because it was medically necessary for me to have more than that number. They said my doctor could call and make a request. He called and they agreed to cover 18 pills. I received a temporary increase to 18 pills a month for one year, renewable each year by going through the same process. That saves me up to $2880 a year.4
-Additionally, numbers of physical therapy/occupational therapy visits can be appealed. Our plan covers 30 PT visits for Tristan per year. He needs significantly more than that number. When the 30 are up, I write and document the medical necessity for him to receive more based on his anatomical defects. I state the skills he is getting with the visits and how they are necessary for his functioning. The physical therapist sometimes needs to include a letter and our pediatrician needs to write a prescription for the services.
Be organized. Take notes. Document everything
No matter what drug, service, surgery, or treatment you are appealing, you must be organized, take notes, and document everything. The key to my system is my medical binder. Have one for each family member. To see how to organize this essential tool, read my blogpost here.
Keep copies of your lab results, operative notes, and copies of all communication to/from your insurance company.
Be sure to have a fully documented medical history.
Save letters that were successful; if you need to repeat an appeal annually (like my migraine drugs and Tristan’s PT visits) then you will have a document that just needs minor tweaking.
Take notes on conversations (including dates and full name of the person you spoke with) at the company or doctor’s office. I learned that tip from my grandfather, a court stenographer for over 50 years: always keep track of the date, time, and name of the person you talked with. It may not be enough to prove your case, but if you can say “I spoke with (first and last name) on (date)” it lends credence to the fact that conversation took place.
Obviously, this post is not a comprehensive list of all types of conditions and how to win appeals for them. I know there are many readers who have had/will have experiences different from my own. I cannot tell you what will work for you; I can only tell you what has worked for me. I hope that by doing so and sharing some of these anecdotes you will learn something that you can apply in your own case. I realized while writing this piece over the past few weeks that there is so much to say about it. I’d like to consider this post an introduction to the topic; I will definitely revisit it again in the future.

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