Trying to understand Ins. Company's denial

[TLF]

Hi Big Blue,
First of all, you are WONDERFUL for even doing this!!!!! :laugh: Insurance is such a confusing mess for the rest of us!

My 6-yr-old son was recently denied coverage, and I'm trying to understand the letter from our ins. company.

Some background: He was evaluated by a neurologist who reported "significant for possible auditory processing symptoms . . . significant neurologic abnormalities--difficulities with speech articulation, finger apraxia, weak hand intrinsics, finger chorea,clumsiness of gross motor movements, impaired tandem balance, and significant sensory processing symptoms."

He then was given an evaluation by an Occupational therapist who agreed with her findings and recommended Occupational Therapist (OT) for 6 months or more.

Our insurance co. is Regence Blueshield, with a plan called Boeing Traditional that apparently is packaged for the employees at management level and is not as liberal as what they provide for union employees.

Their letter to us stated "the documentation submitted (both the neurologist's and Occupational Therapist (OT)'s reports) did not clearly establish an underlying illness or injury in the prenatal, perinatal or early childhood timeframes, as required by the Plan for consideration of medical rehabilitation benefits."

This makes no sense to me! My son has to have been actually "injured" to have something wrong with him?? Can you shed any light on what they mean . . . and is there anything I can say that would have any impact in an appeal?

Thanks SO MUCH!!! I'm sure this takes a lot of your time . . . and is SO appreciated!

TLF

 

[bigblueagain]

yep. I hate to tell you but most carriers consider "rehabilitation" benefits as eligible for only what is considered short term acute accident or illness.( and rehabilitation in this case includes Occupational Therapist (OT),PT and speech normally). The type of problems you are describing are often considered under a development disorder, which is and of itself not necessarily considered a "medical" diagnosis. Having said that, there are a couple of things you can do. Very first thing is to call the Customer Service for Regence and ask for the "appeal" process in regards to decisions based on 1) benefits and 2) medical necessity. I believe you might have a better chance if you go the medical necessity route. IF this is an HMO they have to have expedited appeal processes in place. Again this will be noted in your benefit booklet. The reason you call CS is that they should document your call, which should put them on notice that you will be appealing. Then you also need to ask who exactly will be doing the review. Most first level appeals for medical necessity go to the medical director of the carrier. Many times they do not have the expertise in the area of therapy being requested. In such case most carriers now have subspeciality boards where like type physicians of those who ordered the therapy will be reviewing the request. You should submit as much supporting documentation as possible. If they can't give you the name of the specialist who will review, or if it is the medical director for the carrier, then ask what the second level appeal process is. You may have to go thru several levels. Most of the time, if you still don't agree with their findings, you probably will be able to ask for an independent review by an outside agency. It sounds like the plan is a fully insured ppo however, and usually the employer does not go out of the benefit boundaries. This has to do with the risk and also what is called reinsurance. Your son also does not have a life or death type of request, so expect it to take some time. I would also encourage you to start looking to the school district.....I really don't think you may win this one. But if you go in with some of the questions as above, at least they will know that you aren't the typical consumer who just takes no lying down. Let me know what you find out. BLUE

 

[TLF]

Thanks Big Blue!! /importthreads/images/graemlins/cool.gif

Sigh . . . doesn't sound too promising, but I really appreciate your experience.

Insurance IS covering a tiny bit under the "developmental" umbrella (WA state requires it). But it's only $1000/year until age 7. We passed the $1000 in the first 2 months, and my son turns 7 next month. Guess we should just be happy we at least got $1000 out of it . . .

Thanks again,
TLF

 

[bigblueagain]

well I suppose after seeing this (the fact you did have some coverage after all but have already maxed it out), that you probably won't be able to get any additional. The carriers are REAL testy when a state mandates some type of coverage like you described, and feel they have done their job when they give what they have to. Sorry but this is just the way it is. BLUE

 

[LisaG]

Something that you might consider is looking within you benefits to see if they can be obtained using a different benefit category of your policy. Not likely to work, but you might be surprised. I have seen plans that have one set of benefits under "medical" and an entirely different benefit level under "mental health", "rehab", etc.etc., but the procedures could be classified in one or all of them. Ask the ordering physician for advise since they may know how to get around a particular plan's denials. It's a long shot, but can't hurt to ask. And complain to the employer who is providing the insurance. A large company is probably self-insured so you probably won't get anywhere (and I'm sure that yours would be this), but some only pick coverage through outside companies and if they hear enough complaints about poor benefits, they may look to other companies during the next session of insurance hunting. Good luck!