Guest guest Posted March 4, 2002 Report Share Posted March 4, 2002 My insurance Co, Health Net has denied speech therapy for my 4.5 y.o.son with verbal apraxia. At first they stated that he would not make any significant progress within 2 months (the maximum period of coverage). When I sent notes from my SLP to dispute this, they changed to saying that verbal apraxia was not a congenital disorder. Although, Dr. Agin sent them a letter about this, they continue to deny therapy. They are now offering me a level 2 appeal which is done by phone. I requested that a Neurodevelopmental Pediatrician and a SLP with childhood apraxia experience be included in the evaluation. I was told that they are not required to do this. Any suggestions on how I should proceed? I will file a complaint with the Insurance Board, but I am not expecting much from that. Should I hire a lawyer? I know it sounds like alot of effort to get them to pay for a very limited benefit, but at this point it has become a matter of principle. I just can't understand how an insurer can flatly refuse coverage for a service that meets the benefit criteria. Thanks for the help. Jackie Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 13, 2002 Report Share Posted May 13, 2002 Hi Suzi: Aren't we all....;-( First of all, I would speak with a customer service representative about your coverage limits. Your plan may NOT cover brain injury sequelae - you get what you (or your employer) pays for. Assuming that it is an included benefit, I would then consider that perhaps because the patient is a child, the insurance is assuming it is a developmental disorder, which is often not covered. I would talk with a customer service representative and clarify this. As you may or may not know, the people they use as the grunts to do initial claim review are grade gamma semimorons, who simply punch a few numbers into a computer, and the computer tells them what to do. The CSR's are usually fairly well educated in the nuances of your and other plans, and will probably give you an accurate readout of what the story is. Good luck, Larry Laveman, MD Consultant, CHERAB http://www.apraxia.cc --- In @y..., " luckygmstwife " <suzi_knowles@p...> wrote: > I need help with insurance denial. > > We've changed insurance in January, and the new insurance (Aetna) > has denied coverage. > > My daughter has a brain injury from when she was 6 weeks old. > > The insurance covers restorative speech for brain injury, but they > say she is denied because she could not talk when she had her brain > injury. > > I remember reading somewhere that this is against the law. If an > insurance company covers speech for an adult that has a brain > injury, then they have to cover for a child that had a brain injury > before they could talk. > > Can anyone help? I am soo sick and tired of insurance. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 13, 2002 Report Share Posted May 13, 2002 I just thought I would throw my 2 cents in. (LOL) I can't speak on the brain injury but I can speak on being tired of insurance companies. My daughter was born with a kidney and bladder disorder and has developmental delays.........the doctors think from the surgeries. My son has ADHD, Tourette Syndrome and OCD. My daughter's kidneys were repaired so none of this is life threatening. I have no problem with them paying bills......knock on wood......they do that fine. BUT.......My husband's company changed life insurance companies starting January 1st and my kids still have no insurance. We are still fighting them. They keep sending new forms to have the different fill out. I know these doctors are getting tired of this. It's the same questions over and over. I think the insurance company thinks that people will just get tired of it and will give up..........but not me. My kids deserve the coverage and their gonna get it. I will fight it as long as it takes. [ ] Re: Insurance Denial Hi Suzi: Aren't we all....;-( First of all, I would speak with a customer service representative about your coverage limits. Your plan may NOT cover brain injury sequelae - you get what you (or your employer) pays for. Assuming that it is an included benefit, I would then consider that perhaps because the patient is a child, the insurance is assuming it is a developmental disorder, which is often not covered. I would talk with a customer service representative and clarify this. As you may or may not know, the people they use as the grunts to do initial claim review are grade gamma semimorons, who simply punch a few numbers into a computer, and the computer tells them what to do. The CSR's are usually fairly well educated in the nuances of your and other plans, and will probably give you an accurate readout of what the story is. Good luck, Larry Laveman, MD Consultant, CHERAB http://www.apraxia.cc > I need help with insurance denial. > > We've changed insurance in January, and the new insurance (Aetna) > has denied coverage. > > My daughter has a brain injury from when she was 6 weeks old. > > The insurance covers restorative speech for brain injury, but they > say she is denied because she could not talk when she had her brain > injury. > > I remember reading somewhere that this is against the law. If an > insurance company covers speech for an adult that has a brain > injury, then they have to cover for a child that had a brain injury > before they could talk. > > Can anyone help? I am soo sick and tired of insurance. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 13, 2002 Report Share Posted May 13, 2002 After I posted about speech being denied, our insurance company came through. A wonderful woman from Aetna contacted my husband's company's insurance rep. The rep faxed an exemption for my daughter. My daughter is now approved to get speech. I actually think the person from Aetna that was helping us did above and beyond what she was supposed to, and my husband and I are very grateful. I think it also shows to never give up on insurance denials. > Hi Suzi: > > Aren't we all....;-( > > First of all, I would speak with a customer service representative > about your coverage limits. Your plan may NOT cover brain injury > sequelae - you get what you (or your employer) pays for. > > Assuming that it is an included benefit, I would then consider that > perhaps because the patient is a child, the insurance is assuming it > is a developmental disorder, which is often not covered. I would > talk with a customer service representative and clarify this. > > As you may or may not know, the people they use as the grunts to do > initial claim review are grade gamma semimorons, who simply punch a > few numbers into a computer, and the computer tells them what to do. > The CSR's are usually fairly well educated in the nuances of your and > other plans, and will probably give you an accurate readout of what > the story is. > > > Good luck, > > > Larry Laveman, MD > Consultant, CHERAB > http://www.apraxia.cc Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 14, 2002 Report Share Posted May 14, 2002 I also was originally denied coverage for speech therapy by members of Cigna's Health Service Department and told to look to my town for help. I didn't accept this and instead insisted that I either speak to the Medical Director or that they give my daughter's info to the Med. Dir. As Dr. Laveman also stated, I contacted my client rep who made sure that the Medical Director was the one making the decision. Suddenly, they determined I was covered for speech even though I was previously told it was excluded. Good luck, Carolyn Quote Link to comment Share on other sites More sharing options...
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