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Insurance and Much Needed Therapy

Posted by on Jul. 15, 2013 at 8:41 AM
  • 22 Replies

Background:  We are in the process of getting our son pinpointed on the spectrum.  I'm sure all of you understand how time consuming and gruelling this task is.  I just found out that our medical ins considers this a learning disability, just like dyslexia, and refuses to pay for anything.  Have any of you gone through this?  Anyone have any suggestions. 



Just to clarify: we make too much money to qualify for any state medical welfare assistance, and definetly not enought money to pay for his therapy out of pocket.  We have 3 other children in our household (4 total) so focusing all of our time, attention, and money into one is not doable. 


Eited:  I did it ladies I won.  I sent them a certified letter threatening them with legal action, along with copies of all of his health records and diagnoses.  I included all the scientific reasearch stating that it is now considered a neurological disorder not a "learning disorder," and then sent them a copy of their own policy hand book with the highlighted portion staing that they cover all neurological ailments! 


Thank all of you for your support and suggestions.


by on Jul. 15, 2013 at 8:41 AM
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Replies (1-10):
Monkeymama930
by on Jul. 15, 2013 at 9:42 AM
My son was frist dignosed with SPD, and the insurance kicked if back saying that really does not exist. So we want 7m paying out of pocket for everything.
Well after months of taking him to therapist and doc. His pedi finally said this is ridiculous! And finally did an autism test in his office and my son hits enough of the markers to qualify. And supposedly starting this week the insurance will start picking up on some of his therapies.

So I guess my advice try for a redignosis?
LicParaMommy
by Member on Jul. 15, 2013 at 9:49 AM

Sorry, what is SPD?

cjsmommie98
by Member on Jul. 15, 2013 at 9:56 AM

Also if he is on the spectrum u can get a waiver for state aid and file for ss

ineedcoffeemom
by Brittaney on Jul. 15, 2013 at 10:20 AM

If he already has an autism dx you can get on a state-funded program waiting list (which will be really long, but at least you'll know there's help coming on down the line while you try to do whatever you can now)

Is your insurance self-funded or fully-funded, because if its fully-funded there are laws requiring certain therapies to be paid for ..... you just have to find out what those specifically are in your state and then see if your son's ped can file the medical code that would require those therapies.

I'm having a hard time myself right now because our insurance is self-funded so it's alot less regulated.

ineedcoffeemom
by Brittaney on Jul. 15, 2013 at 10:21 AM


Sensory Processing Disorder

Quoting LicParaMommy:

Sorry, what is SPD?



LicParaMommy
by Member on Jul. 15, 2013 at 10:26 AM


Unfortunately it is self funded!  I know - damn loop holes!  They do not even cover immunizations.  We have to pay for that out of pocket.  They were pissed to find out that they had to cover my tubal after my last son due to  the Health Care Act.  I know there are a lot of people that have issues with the new health care laws , but in a lot of circumstances it will help us (forcing the ins to pay!) We pay alot in premiums to only be told that they will not pay for this or that.  Unfortunately it going into full effect was pused back to till 2016.  I'm not waiting till then.

Quoting ineedcoffeemom:

If he already has an autism dx you can get on a state-funded program waiting list (which will be really long, but at least you'll know there's help coming on down the line while you try to do whatever you can now)

Is your insurance self-funded or fully-funded, because if its fully-funded there are laws requiring certain therapies to be paid for ..... you just have to find out what those specifically are in your state and then see if your son's ped can file the medical code that would require those therapies.

I'm having a hard time myself right now because our insurance is self-funded so it's alot less regulated.



LicParaMommy
by Member on Jul. 15, 2013 at 10:27 AM


Oh ok.  No his tentative diagnosis is ASD, we just need to know where he falls to really push forward for treatment.   I've honestly thought about going ahead with his treatment and then filing for bankruptcy protection.  I feel really bad about admitting that, but willing to do anything I have to.

Quoting ineedcoffeemom:


Sensory Processing Disorder

Quoting LicParaMommy:

Sorry, what is SPD?





LicParaMommy
by Member on Jul. 15, 2013 at 10:28 AM

Thank you for the suggestion.  I am going to have to look into that.  Any idea on where to start?


Quoting cjsmommie98:

Also if he is on the spectrum u can get a waiver for state aid and file for ss



JTMOM422
by Brenda on Jul. 15, 2013 at 11:28 AM

I don't understand how they consider it an learning disability. I would check your state laws on this or check IDEA to see if they can do this. autism is a neurological disorder not a learning disabiliy. I think your insurance is trying to get over on you. If they insist that it is a learning disability go to your doctor and get a written letter stating that it is a neurological disorder.

RaevenJadeAK
by on Jul. 15, 2013 at 1:04 PM

Go talk to your local Social Security office and Department of Public Assistance (usually a division of Health and Human Services).

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