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.