Tuesday, July 06, 2010

Healthcare Reform and Children With Special Needs

So, this healthcare reform thing. Yeah.

Here's my take -- bearing in mind, of course, that I'm not an expert. I'm not a medical professional. I'm not a lawmaker. What I am is the mother of a child with significant special needs. As such, I find it offensive and distasteful when I see that insurers are allowed to deny claims solely for business reasons.

In a denial I personally received from Aetna, I was told, "Not every medical service or supply is covered by the plan, even if prescribed, recommended, or approved by your physician or dentist. The plan covers only those services and supplies that are medically necessary and included in the What the Plan Covers section." (emphasis in original)

Here's the thing: Medically Necessary is TOTALLY DIFFERENT from WHAT THE PLAN COVERS. My pediatrician, my developmental pediatrician, my speech therapist, my occupational therapist, my son's teacher, and every medical and developmental professional who has ever evaluated him has said that his therapies and treatments are medically necessary. And yet, Aetna says:

"the plan does not cover [speech] therapy when it is used to improve speech skills that have not fully developed."

I have a hard time maintaining my composure when I read that statement. Why is it legal for a plan to exclude such coverage? Wouldn't it make more sense to cover such treatment, just as you cover it for someone who had speech function but lost it after a stroke? From a business standpoint, too, it makes more sense to cover these services for children. With intensive speech therapy in their youth, many children will go on to become contributing members of society. Without it, their chances for such success are much less.

My God, they say FLAT OUT:

"Examples of non-covered diagnoses include Pervasive Developmental Disorders, Down's Syndrome, and Cerebral Palsy, as they are considered both developmental and/or chronic in nature."

Words fail me.

WHY IS THIS ACCEPTABLE? Why is it legal for a company focused solely on profits to make medical decisions that affect my son's quality of life permanently?

Obviously, health insurance reform is necessary. But I'm not seeing how the new law helps me, or the thousands of parents like me, who have children with special needs. I mean, yes, we can get insurance coverage for them. Yay! But what good is that coverage if it doesn't cover anything they need?

(Side note, perhaps irrelevant: I'm also tired of hearing about how awesome Canada is. For some things, it's great, I'm sure. But I had a Canadian woman in my kitchen on Sunday who lives in Toronto and went to her doctor. After an exam, he told her she needed an MRI. The appointment was made for 2 or 3 months out. And when it showed THYROID CANCER, her radiation treatments were scheduled for another 3-4 months after that. What the what?)

I'd like to hear from the rest of you. Do you think the new laws will help you? How?


Unknown said...

We have had run-ins with insurance companies and also governmental agencies (Federal and State). Near as I can tell, they are equally incompetent. The big difference seems to be that insurance companies can be incompetent for a lot less money than the government. So in short, I would rather see small, logical, incremental improvements to health insurance regulations, not another huge bloated government mess.

Shosh said...

We have the same problem. My 6 year old needs speech therapy yet our PPO won't cover it because it's not the result of illness or injury. I mean, really. Does that mean that the only kids that can get speech therapy are ones that get their tongues chopped off or have a stroke? It's just ridiculous. I do not have high hopes for healthcare reform. I can't see it changing anything for us. But I agree...socialized medicine is not the answer. If we lived in Canada, he would get speech - but probably after 3 years on the waiting list. I'm wondering how Israel's system measures up, though...

Angie said...

Aetna sucks! I had an issue with them 20 years ago...got them to pay, but they then dropped everyone in our small business!

My friend from Canada also says that they wait forever for testing and treatments.

sugar magnolia said...

Don't get me started on insurance. While were are blessed to have wonderful private insurance, and Medi-Cal as a secondary to boot (pays for her co-pays) insurance won't pay for dd's hearing aids. They will pay for hearing tests, which diagnose her as deaf/hard-of-hearing...but not hearing aids. Glasses yes. Not hearing aids. Which, by the way, cost us $3000. Grrr....

Ellen Seidman said...

Abbie, I have fought Aetna mightily...AND WON. You have to email me. It is mind-boggling, but it is possible to win.

Shosh, my son had a stroke and they STILL denied us speech therapy.... I was told it's going to be a lifelong condition, they don't cover it.

moplans said...

I am not sure what to wish for. Sometimes I hate my socialist system but when I read posts about people fighting with their insurance company I realise that is not much better. I do think that once you get coverage that the private system is far superior to this mess.

Who is your friend from Toronto??? Is thyroid cancer one that doesn't spread quicky? I hope so.
I have usually been seen very quickly for anything urgent. Like anywhere I have discovered it helps to know people and be a pain in the butt.