Yesterday, we received a letter from Aetna, in response to our second appeal. Among the highlights:
The appeal stated that D. had a high arched palate consistent with the diagnosis of Sotos syndrome. This is a congenital defect and the cause of his delayed speech. Prior to seeking speech therapy Aetna advised D. would be eligible for speech therapy benefits. You feel Aetna should pay claims based on the coverage you were provided by Aetna Member Services.REALLY? I mean, REALLY? You mean to tell me that because my son was not diagnosed with his MUTATED DNA AT BIRTH, it's not a birth defect? REALLY????
Medical records supplied by [your therapist] indicate D. was diagnosed with Sotos Syndrome at the age of two by Texas Children's Hospital. Medical records do not support a congenital defect; as a result, benefits are excluded.
OK, so obviously, the person who wrote this letter has NO IDEA what Sotos syndrome is, and could not be bothered to (1) be consistent with the capitalization, (2) do even the MOST CURSORY GOOGLING, or (3) God FORBID, speak with AN ACTUAL MEDICAL PROFESSIONAL.
But let's continue.
You'll forgive me, Aetna, if I say that is just plain and simple BULLSHIT. You can't find the records? Whatever. PROVE THEY DON'T EXIST.
Furthermore, we were unable to locate phone records prior to treatment that confirmed speech therapy would be covered for delayed speech.
But my FAVORITE part? Oh, that's towards the bottom of the second page. It says:
You know what, Aetna? It's on. IT IS FRIGGIN ON.
Speech therapy has been denied according to your plan benefits. Speech therapy services that were previously paid will be adjusted due to the exclusion of your plan.
We are consulting lawyers today. I am hoping to find someone who can file not under ERISA, which is heavily weighted in favor of insurance companies. I want a jury trial. I have visions of a John Grisham hero-like lawyer taking on our case for free, because I'm cute, and winning. I will also settle for something less dramatic. My brother's father-in-law is a lawyer in another state, and he called this morning with some questions, some advice, and some ideas, so we'll see what happens next. But IT. IS. ON.
20 comments:
(And I mean no offense to anybody's sensibilities here) FOR FU@K'S SAKE?!!?!??!?!? I would be on the phone DEMANDING to speak with a DOCTOR on staff and I would also send a letter with your attorney's name. The other thing I would do is see if your doctor's office will help you fight, because sometimes they have the inside lines on these things.
I am SO SO SO sorry you are dealing with this.
I emailed you.
So sorry about this crapola
Doesn't your state have an agency where you can complain about your health insurance?
Maryland and DC have it. I may have to use it, but I should think that might be your first step after appeals with the insurer. Look up: "Your state name health insurance complaints" in Google to see if you can find the agency.
Here is a link to more information about the genetics of Sotos Syndrome that was prepared by our genetic counselor and which has links to some useful resources for those dealing with this condition: http://www.accessdna.com/condition/Sotos_Syndrome/346. There is also a phone number listed if you need to speak to a genetic counselor by phone. I hope it helps. Thanks, AccessDNA
Sorry you have to go through this but I have Aetna and My kid was diagnosed with Sotos also. I haven't had a problem. All of my claims are paid for all therapies. ST, OT and PT are all covered since birth and my daughter is now 4. Sometimes the wrong diagnosis codes are entered. In order to obtain coverage for therapies the diagnosis has to be developmental delay. Also, it's all about what your employer will cover.
I've head Aetna before when I was working for Broker Dealer Lawyers and let me tell you, they are no picnic to deal with. I was run up and down the stairs and go so winded. I called up and got a voice operator and voila, put on hold.
I can totally understand where you're coming from. My cousin is a doctor.
I wanted a new 2011 Lexus but they wouldn't give it to me for $1,000. The nerve of those car dealers!
Why does everyone think that Insurance covers everything for everybody? The limits of you specific policy are the limits you live with (or not). Pay more and get a better policy (or car). Unfortunate situation but stop whinning...
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