Friday, September 25, 2009


I am sure some of you know what we have been going through with our insurance company lately. So I am sorry if I am repeating myself, I am posting this to prove a point and to say once again that our health insurance system is broken. I'm not getting into the politics of whether what the government is trying to do with health care is right or wrong. I'm simply saying, that as it stands now, we are being let down by the system.

Forgive me for being lengthy with this post, I'm hoping that this will help raise awareness and help someone else out in the future. I am also looking for any advice from those whom have either been through something similar or know how to work the system better than we do, or opinions on whether you think we really have a leg to stand on during this fight?

Our insurance company has been denying all claims for PT and OT since May stating that the diagnosis of developmental delay is not covered under our plan. So I gathered up all the documentation I could find proving that Haley's delay is most certainly due to a very specific cause, Joubert Syndrome. I very confidently put all my little documents in the mail last month, feeling like I had all my ducks in a could they deny us now, here they had the proof the needed!!!

Well, much to my dismay, I opened the big fat denial letter today. It was like a sucker punch in the gut. My pessimistic side told me not to get my hopes up, but deep down I thought for sure they would agree to pay....who was I kidding, health insurance companies are nothing but money grubbing evil empires. So now they are trying to slip through a different little loop hole. Blaming it on developmental delay didn't work, they are now going to try the"this is not an acute illness" approach. This is the letter I received (some parts have been removed to cut down on redundancy):

"In your appeal, you requested we reconsider and allow the PT and OT because you stated these services are medically necessary due to her Joubert Syndrome.

This review confirms the initial determination that the PT and OT is not eligible for reimbursement. Under the plan, benefits for ongoing therapy in this case are not covered. PT and OT are covered under the short term rehabilitation benefit which provides coverage for acute conditions when therapy is expected to result in significant improvement of the person's condition within 60 days from the date the therapy begins. In this case, the condition is an ongoing and not an acute condition.

The denial of coverage is based solely upon the reasons set forth above. No other basis for exclusions (e.g., medical necessity of the services or supply) that may be applicable to the circumstances was evaluated at this time. Therefore, we are upholding our previous determination.

Short-term rehabilitation is therapy, which is expected to result in improvement of a body function, which has been lost or impaired do to: an injury, a disease, or a congenital defect. Furnished to a person who is not confined as an inpatient in a hospital or other facility for medical care. This therapy shall be expected to result in significant improvement of the person's condition within 60 days from the date therapy begins."

I am confused by the fact that our plan will pay for unlimited therapies, with no lifetime maximum visits but yet they only consider payment for acute cases. Why would an acute illness need unlimited amounts of therapy......fishy, don't ya think? Also, why would they every pay for therapy from the start if they knew all along that she had a chronic condition? Furthermore, they paid for therapy for approximately 120 days before they began denying the claims....I thought they had some ridiculous 60 day rule????

It also befuddles me to see in writing that, according to their standards, Haley has not made "significant" progress!!!! This is a little girl who in January did not even have the grip strength to hold our hands to come to a sitting position, and today she is on the verge of walking. I am sorry, but that is VERY significant progress!!!! I take that as a personal insult to Haley to say she has not made significant progress.

So, our next course of action is to file an, albeit useless, second appeal, which will include documentation from our PT and OT proving Haley's SIGNIFICANT progress. All we can do is keep fighting and keep trying to prove our point. Haley will likely require some form of therapy for most of her childhood, so we are just in the beginning of therapy. Insurance companies rely on the assumption that most people will back down and not fight, they also are slimy bastards and will slip through any loophole that they can find or create. We will not go away quietly, I declare WAR!!!! Won't you join me???


Christina said...

Oh no. I'm so sorry!! Keep fighting!! I wish I had some advice, but I have none. Insurance companies don't care about us, or our kids. *hugs*

Krista said...

You are awesome!!!! Keep up the good work.