If you are the parent of a child with brain injury or cerebral palsy, you know the red tape that goes along with insurance. It’s incredibly frustrating when a treatment or therapy that can have a significant impact on your child’s health and well-being is denied by your insurance company. But it happens all the time. Being prepared for such events, and knowing how to handle them, is your best defense.

Situations in W\which Benefits are Denied

When all is said and done, most insurance companies will look for just about any reason to deny coverage. Typical situations in which benefits are denied include the following:

• Certain treatments and services—such as home services, skilled nursing care, and durable medical equipment—are excluded. You can generally find these under the “exclusion” area of your policy.

• The child’s care is not medically necessary. If you are like most parents, you are probably under the impression that your child’s doctor has the final say in whether your child’s treatment is necessary. Unfortunately, most insurance companies reserve the right to determine whether the treatment is medically necessary.

• The medical treatment was not pre-approved. Yes, an insurance company can deny benefits if paperwork was not filled out correctly—and many do, even if the treatment is considered necessary. Parents must take care to ensure that all treatments are submitted for pre-approval.

• The child’s care is custodial. If an insurance company says that it will not pay for your child’s care because it is “custodial,” it means that they are making a judgment that the treatment will not contribute to the child’s recovery or gains.

• If the medical report from the child’s doctor does not meet the definitions of the insurance policy. For example, a doctor can prescribe “assistive technology” that does not meet the carrier’s definition of “assistive technology.” Or, with automobile policies, a child can be brain injured in an accident involving a vehicle that does not meet the carrier’s definition of “motor vehicle,” such as motorcycles, dirt bikes, ATVs, or mopeds.

• If the requested treatment is experimental or alternative. Despite the fact that many experimental and alternative treatments have been proven to be helpful to children with brain injury and cerebral palsy, few insurance companies cover them.

• The child has reached her limit in a particular category. For example, the benefit for durable medical equipment may be depleted on one wheelchair, so no benefit is left for other equipment that’s needed.

• If you’ve signed away rights before the full extent of your child’s injury has been determined. This happens most frequently when a third-party insurance is used. Don’t sign any insurance forms before an attorney has had time to review them.

Conversion

One thing parents can do when treatment is denied due to lack of coverage is to ask for a “conversion.” Essentially, a conversion allows you to swap a covered benefit for an uncovered benefit. For example, let’s say that your doctor believes that your child will benefit from Hyperbaric Oxygen Therapy (HBOT), but your insurance policy doesn’t cover it because it’s considered an “alternative” treatment. However, your child does have coverage for 30 skilled nursing visits that you and your child’s doctor don’t believe are as necessary. You can ask the insurance company to pay for HBOT in place of the skilled nursing benefit.

Parents who successfully convince insurance companies to do a conversion have come prepared with arguments that convince the company that the conversion is best for the child and the insurance company. In other words, they are able to tell the insurance company—convincingly—how swapping the benefits will save the insurance company money in the long run. Arguments are best made using statistics, as well as the testimony of your child’s doctor and medical team. Be sure to present your argument to someone at the insurance company who has the power to make decisions.

Bad Faith

If you feel that your insurance company is denying benefits without a good reason, they may be acting in “bad faith.” In many states, state laws can protect you from these kinds of situations.

If you think your insurance company has acted in bad faith, contact us for help. In many cases an insurance company that acts in bad faith is liable for punitive damages, lawyers fees, interests, and court costs. Often, a simple letter from your attorney is enough to get the insurance company to fix issues or problems that are occurring.

If your child is still being denied therapies and treatments, you don’t have to sit back and accept it. There is an appeals process that can help your child gets the therapies and benefits he needs. Remember that knowledge and advocacy are key to your child getting what he needs. When navigating the red tape of insurance issues related to brain injury or cerebral palsy it often helps to have an experienced, qualified attorney on your side. Contact us to find out how we can help.