Insurance Coverage Denied

“Anyone who has tried to talk with my son could easily see that Kai needs speech therapy. Yet his health insurer has now deemed that it is not necessary.” - From today’s column in the Patch.

Click here to read the whole outrageous story. You will not want to miss it.

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.

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.