04/05/99

When Insurance is Denied

Q: I read last week's article, (about hospitalization of a child in crisis) with great interest. We would like to hospitalize our son, but the insurance company has denied admission because they claim his dangerous outbursts are short-lived and can be controlled with medication. There is some truth to this, except that the medication has caused him to gain 30 pounds and become lethargic and depressed. We want him hospitalized, taken off all medications and evaluated and remedicated properly while under the supervision of hospital staff. What can we and other people do to take the control of these decisions out of the hands of the insurance companies and put it into the hands of the doctors and the families they treat?

A: There are no easy answers to your question, because there are so many insurance companies and many of them offer several different plans for medical coverage. So I'll attempt to answer your question from personal experience and also suggest some resources you can consult.

My family's medical insurer bases decisions about coverage on group statistics, but also provides an appeal process to take individual circumstances into account. For example, their guidelines pay a fixed amount for gall bladder surgery for a fixed number of days in the hospital (barring complications). They refuse to cover claims for more, unless they receive proof of extenuating circumstances. The proof requested is usually a letter from the physician(s), stating the reasons for higher charges (such as surgical complications or unexpected post-operative events necessitating a lengthier hospitalization). We have initiated the appeals process twice and resolved both payment issues to everyone's satisfaction.

Therefore, I suggest that you discuss the situation with your son's physician and ask him or her to initiate the appeal process, stating exact treatment recommendations and the reasons behind them. When conducted in good faith in a timely manner, I think such accountability allows for protection of both the insurer and the insured, by establishing cost control standards and requiring justification for diagnostics and treatment, especially in non-emergency situations.

If the appeal process leads to a dictatorial response from the insurance company, with no opening for discussion or accommodation, call the Connecticut Children's Health Project at 800-434-7869 or the CT Office of the Child Advocate at 800-994-0939 for advice about how to proceed.

Author's Note: The child advocacy process can unfold in a linear, logical manner or require several steps backward and sideways before going forward. But no matter how frustrating or time consuming, your child's welfare is worth the effort. Keep asking questions and seeking the support of qualified professionals and trusted friends until you are able to remove obstacles to your child's developmental progress.

Please send questions or comments to bbruno@snet.net.