Saturday, December 13, 2008

I almost fell for it...

I had another long and frustrating call with the insurance company yesterday regarding Will's speech therapy. After going back and forth again with the incompetent representative who called autism a "procedure" and went on to call Will's therapy "cosmetic," I came to some frightening and disheartening realizations. At one point, I'd asked to speak to the supervisor. While I was on hold for over five minutes, I had an opportunity to re-read my insurance plan's position on speech therapy coverage. After reading the following section, I had an epiphany - our insurance company has EXPLICIT exclusions for covering things like speech and occupational therapy if a child is diagnosed with autism. Here is the paragraph:

Speech therapy is generally not appropriate for use in prelingual children when there is no identified underlying medical condition or there is no possibility of the child reaching an age-appropriate level of speech (e.g. autism, pervasive developmental disorders developmental delay or mental retardation; the inability to construct sentences, stuttering or tongue thrust).

This made me look at Cigna's autism coverage. In a nutshell, it appears Cigna considers proven autism treatments such as speech and occupational therapy to be educational, not medical, in nature and will therefore not cover any of the treatments once a diagnosis is in place. Here's the kicker - our insurance company will pay the $1,000 to have a child evaluated for autism, but once that child is evaluated and is given a diagnosis, it appears Cigna has grounds to deny coverage. There is something wrong with that.

Now I really needed some clarification so I continued to hold for the supervisor who never got on the phone. I was told she was busy with conference calls, yet she apparently had enough time to point out something in a manual for the still incompetent representative to explain to me. The rep finally put me into her voicemail where I left a very focused message that I need an answer to - If my child is diagnosed with autism, will Cigna cover his speech therapy? The supervisor never returned my call.

As I'm sure you can imagine, I was devastated when I got off of the phone. I called Ryan sobbing and told him what I'd figured out. No offense to Frisco ISD and the program Will is in now, but in our opinion the school district simply doesn't provide the intense therapy and focused attention Will needs right now. If we hope to have him mainstreamed in a year or two for kindergarten, he needs more than what the school district is supplying him. I'm afraid that if we don't continue to provide these services for Will, we'll fail to maximize his potential. We're now considering private school that we can't necessarily afford, but will do what we have to do for Will.

This isn't over - we'll keep fighting. But yesterday's round went to the insurance company.

1 comment:

Barbara said...

Would this be considered discrimination, and can you go all the way to Supreme Court?? Have you thought of this?? I am SURE you are not alone in this!