Insurance Coverage of Occupational Therapy Denied

In Illinois, a law was enacted two years ago that requires health insurance companies to provide coverage for the treatment of autism spectrum disorders. When the law was passed, it gave hope to many families that insurance would cover more of the therapy that so many of our kids need. But, from my perspective, the reality is that insurance companies are looking even harder for ways to get out of their obligations.

In our most recent case, my son’s insurance company recently stopped covering his occupational therapy (OT) after paying for a couple of years. The reason, they said, is that the therapy was considered maintenance and not restorative, which means that they are saying that my son was not showing progress as a result of his therapy so they were not going to continue paying for it.

As he was actually making progress, we appealed the decision and submitted reports from his occupational therapist that showed how he had improved in every area of focus in his therapy. I figured that it was a no-brainer and that we would win the appeal. My wife, who is usually the one to deal with the insurance company, was skeptical.

She was right.

Yesterday, we got the letter which stated that they will not overturn the previous decision to deny coverage. This time, however, they gave a different reason. They said that the therapy was “not proven to be effective based on the peer review publications available.”

I’m going to have to do more research to find out what type of evidence there is that “proves” that this therapy is effective. But, I can already tell you that occupational therapy is common among kids with autism. And, regardless of whether or not there are studies that show how effective OT is with other kids, the truth is that my son has improved in all areas his therapist is working on with him. That alone should be enough.

The Illinois law says that “treatment for autism spectrum disorders shall include the following care… for an individual diagnosed with autism spectrum disorder…therapeutic care, including behavioral, speech, occupational, and physical therapies that provide treatment in the following areas:… (v) motor planning, and (vi) sensory processing.”

Under those criteria, my son's therapy definitely qualifies. Is it too much to ask that the insurance company comply with the law?

Living with autism can be hard enough sometimes. Having to constantly battle insurance companies adds unnecessary stress.

Enough already. Let my son have the therapy he needs.