Insurance Woes

Many of you know my husband works for a VERY large, VERY well known company. We are a self-funded insurance and because of that they do not have to follow the same laws that are documented in the affordable care act. None of my daughter's medical visits are covered nor does she get any therapy paid for. I decided to write a letter to appeal her medical care denial.

I have spent HOURS on the phone in the last few days crying to customer service associates to find myself at a dead end. I find myself frustrated and annoyed. We did it "all right". We went to school. We got married. We were open to life. We have a child with a disability and we cannot get her the help she needs to find success in the future. I have learned being a special needs mom means being a bad ass and being HER voice. I won't rest until I feel I have done my best.



To Whom It May Concern:
In April 2016, I began the process of advocating for my daughter Seraphina. Since she was 18 months old, I knew something was different about her and in the late winter and early spring months, I knew that a diagnosis of autism spectrum disorder was on the horizon for her and our family.
After visiting our regular pediatrician, we were referred to Hunterdon Developmental Pediatrics. Dr. Audrey Mars had been highly recommended and regarded in diagnosis and assistance in planning for a child’s development through education and therapy. During the process to be accepted as a patient I spent time gathering information and understanding the benefits that our plan with Aetna had to offer. I was surprised to find that our benefits were limited to a diagnosis only and did not provide for any therapy or continued medical coverage.
For a child that is not neurotypical, it is imperative that they receive correct medical evaluations and care so that families can work with the local school districts to prepare and execute the best plan of action for each individual child.
Knowing that we had limited resources through insurance, I threw myself into finding therapy through Early Intervention as well as out of our own pocket through University funded programs both locally and online. Though our daughter was diagnosed as having autism as well as a host of other diagnosis’ our insurance company would not pay for any therapies to help her reach her potential. Since she has turned 3, the Early Intervention Benefits have ended however we are continuing to pay on the services she received over the summer months.
Currently, one in 68 children will be diagnosed with ASD an increase of 30% in the last two years. (Google) With the increasing numbers of children impacted by this disease, we must act fast to help the children suffering on a daily basis with the lack of communication, increased sensations and emotional disturbances this disorder brings with it.
Many therapies have been suggested to help children with ASD grow physically, cognitively and emotionally. These therapies include but are not limited to occupational therapy, speech therapy, ABA therapy services, music therapy and art therapy.
It has been scientifically proven that ABA Therapy or applied behavioral analysis will not only impact but improve the quality of life for children diagnosed with autism spectrum disorder. For further information or to read studies themselves, you can visit Autism Speaks. Here is an article that you may find helpful. https://www.autismspeaks.org/what-autism/treatment/applied-behavior-analysis-aba
This organization has a privately funded insurance program therefore does not have to follow the laws set forth in the affordable care act. It is exceptionally discouraging to know that although we pay into an insurance plan that we are not able to receive the benefits necessary to promote our child towards living the best life she can possibly live. I am fairly certain I am not alone in my belief and that a company with 80,000 employees must have other children that also have been diagnosed with ASD and could benefit from medical treatment and therapies.
Our daughter, Seraphina had to visit the Developmental Pediatrician this past October for a follow up to see how the therapies we had obtained and PAID FOR through Early Intervention and East Strousburg University were impacting her development. It was noted that she had some visible growth however was also diagnosed with two additional medical conditions, one being hypotonia that potentially requires physical therapy. Without the doctor’s notations and orders it would be difficult for me to receive services through our local school district. In December, we will have a meeting to modify our daughters IEP based on this last doctor’s appointment and an FBA done in the classroom at school.
I am writing to dispute our claim EK35V639900 as well as lobby for better medical treatment and services for my daughter and other children in the same position. This current claim is one of many medically necessary evaluations to come and at the cost of $409.00 per visit should be covered. As I have explained to the Customer Service Representatives, this care is only for her medical treatment. I have not tried to have any of her therapies covered by my insurance carrier, I am dismayed that this medical visit and analysis is currently being denied because she currently has an autism diagnosis. It is disgrace that a child with a medical diagnosis such as diabetes is fully covered while my child, who also suffers physically through her daily experiences is looked over because her diagnosis falls under the Autism Spectrum Disorder.
I am disgusted that an organization such as this one which believes they promote family does not consider its employees and their families to be in need of these medical services and therapy benefits that so many other organizations support. These services will not only impact my family but will also span out to our society so that children such as Seraphina grow to be a positive asset not a burden in society.
I would like to speak with someone on behalf of my daughter and the other children who struggle with diagnosis’ on the autism spectrum disorder.
I am grateful for your reconsideration of this current claim and expect that moving forward that this organization will make the right decision to increase services for Seraphina and other children suffering with Autism Spectrum Disorder.

I look forward to hearing from you and can be reached via email, phone or in writing.

Comments

  1. Hey Momma I just found your blog... miss you on FB. Hope all is well. My Rita, we finally know what's going on with her, to some extent anyway. "Off the charts" ADHD. About to get CST for her at school. It's good to be able to put a name to what is going on with your child so that at least you can try and start to do some research yourself but yes, we really do have to put on our boxing gloves and get in the ring for our children . I hope everyone is well and happy!

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