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.

Sick Kid, Grouchy Parents and Insurance Woes

Wednesday was not a good day at our house. Our son was sick and stayed home from school. And, that was actually the relatively better part of our day.

The good news is that Kai’s sickness appears to be nothing too serous – just a cold, most likely – and, hopefully he will be back in school soon. He said he was feeling better this morning and wanted to go to school, but then said he was cold so, we are keeping him home another day. The worst part of his sickness is that he is having even more trouble sleeping than usual. He was up several times for the last two nights now. And, that makes for a very tired Dad, as it is usually me who gets up in the middle of the night when he can’t sleep.

Tired Dad leads to Grouchy Dad. And, having our son home from school all day leads to Tired Mom which leads to Grouchy Mom. But, even that was not the worst part of our day.

No, the worst is getting the news that our son’s occupational therapy is being denied coverage by the insurance company.

The cost of paying for Kai’s therapy out-of-pocket without insurance picking up much of the tab is too much to bear. Of course, we will appeal the decision. But, the risk that we will not win the appeal makes it such that we will, at least temporarily, have to stop the OT that has been benefiting him so much.

We have gone through this before. Kai’s speech therapy was denied coverage and we had to go through the appeal process before coverage was restored. We also had the same problem with coverage when he was getting OT from a different provider. Both the logical and optimistic part of my mind cannot believe that we will not win our appeal. But, logic and optimism does not always apply when dealing with insurance issues. Our frustration with insurance companies is reaching the boiling point and one day, when I am not so tired, I will give this the proper rant that it deserves.

For now though, a sick boy and many other things await so I will have to cut this short. Sorry, no cute pictures today. Grouchy Dad is not in the mood. Such is part of the roller coaster of life with a child with autism.