Insurance Fight Concludes, For Now

Five months ago, our son’s insurance stopped coverage of his occupational therapy saying that they did not feel that he was showing progress.

We immediately appealed the decision. We submitted data from our OT provider that showed that our son actually was making progress.

Two months later, they informed us that our appeal was denied. This time, it was on the basis that most of his occupational therapy was really sensory integration therapy, and that was method of therapy was not proven to be effective.

We quickly submitted another appeal, this time providing copies of research that indicated that sensory integration therapy was effective. We also included a letter from my son's therapist that clarified that sensory integration was just a small part of the therapy she did. And, I noted that a recently passed Illinois law provides for coverage of occupational therapy for persons with autism.

About a month later, I followed up to see if they were close to a decision. They claimed not to have received our appeal documents. It was sent through certified mail so we had signature confirmation that they received it. Oh, they said, in that case we will look for it. Two days later, I called again and they claimed to still be looking for it. Don’t bother, I said. I’ll send it over again. I implored that our appeal be put on top of the pile, given how much time had already passed. Oh sure, they said.

A month later, still no decision. The people I could reach on the phone had no idea when the decision would be made.

Yesterday, three months after we originally submitted our latest appeal, we finally got the decision. It was apparent that our re-sent letter had gone to the bottom of the pile. They took nearly the full 60 days after receiving it the second time to make a decision.

The result: they are still denying coverage. The therapy is not medically necessary, they said. The Illinois law regarding autism coverage does not apply to them, they pointed out.

The denial of coverage is a huge disappointment as, contrary to what they claim, we believe that the therapy was very beneficial to our son. What makes it even tougher, though, is all this bull that you have to go through when dealing with insurance issues. Is it genuine incompetence on their part to lose appeal letters, change the reasons for their denials, and to seemingly ignore all the information you send? Or, are they really crafty and just hoping to wear you down? Perhaps it is the arrogance of knowing that they can get away with it.

Whatever the reason, they win on this one. We are certain that another appeal will not change their minds. And, we are not willing to risk the ordeal and cost of litigation. So, we are throwing in the towel on this fight.

I expect, though, that this won’t be the last fight we have with them. My son’s speech therapy will probably be under scrutiny in a few months. And, we won't be throwing in the towel on that one.