January 27, 2010
PO Box 14462
Lexington, KY 40512
To Whom It May Concern:
This letter is in response to your letter dated January 21, 2010.
You stated that in reviewing our appeal, you decided to uphold your previous decision not to cover our son's speech therapy. We are now requesting a second level appeal.
In your letter, you quote from your What the Plan Covers and state, in part:
Speech therapy is covered for non-chronic conditions and acute illnesses and injuries and expected to restore the speech function or correct a speech impairment resulting from illness or injury; or for delays in speech function development as a result of a gross anatomical defect present at birth (emphasis added).
Our son has a high arched palate consistent with the diagnosis of Sotos syndrome. This gross congenital anatomical defect is the physical cause of his delayed speech function development, and based on that, you should cover our son's speech therapy.
It is impossible to write this letter and not address another issue. You state that you will not cover services for the treatment of delays in speech development. This is morally, fundamentally wrong. In fact, it is utterly reprehensible, and some states have said as much in their court rulings.
It is not easy to rear a child with special needs. It takes an enormous amount of time and patience. The time that we spend fighting with you for basic services could be much better spent helping our children.
If you think that parents of children with special needs will simply give up and do without the necessary services for our children, then you have grossly underestimated us. Should you deny this appeal, in fact, we will bring a civil action under Section 502(a) of ERISA.
As explained in our previous letter, we would like to reiterate that after graduating from state-covered services, we called Aetna and consulted with you to determine where our son could be receive speech therapy in network and what would be covered. We enrolled in that clinic and spent about a year there, during which time our claims were processed and paid normally.
For scheduling reasons, we switched to another in-network clinic, PTC, in August. Again, we verified with Aetna that this clinic was in-network and that our services would be covered. Imagine our surprise when we were told that you had denied the vast majority of our son's speech claims since August.
Despite a complete evaluation and submission of the proper materials, you have continued to deny these claims, after you told us that this clinic was in-network and that our services would be covered. This is unacceptable.
Because we consulted with Aetna prior to commencing in-network speech therapy, which you told us would be covered, and in fact, you did cover and pay for this therapy for over a year, you should pay all past claims. If you choose not to cover going forward -- although we do not agree with this decision, and will fight it using all resources available to us by law -- that is a separate issue. You cannot, however, arbitrarily to decide to leave us responsible for a medical bill of over $1500 that you had previously approved.
We expect these services to be covered and the outstanding bill to be settled by Aetna immediately.
WG and Mr. WG