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My health insurance company has denied my son speech

My health insurance company...

My health insurance company has denied my son speech therapy. He's been diagnosed as "developmentally delayed" at his 18-month checkup and his 24-month checkup. After the 18-month checkup I tried to get him in for therapy, which insurance denied several times. It took 6 months and finally getting a "peer to peer" with our pediatrician and the medical director for our HMO's medical plan. They approved 16 sessions over 3 months. We used them all. My son is progressing but still diagnosed as "delayed." We tried to get him approved for more speech therapy and again it was denied. I can't wait another 6 months to battle the insurance company. What are my options?

Lawyer's Assistant: What state are you in? It matters because laws vary by location.

CA

Lawyer's Assistant: Has anything been filed or reported?

Not yet

Lawyer's Assistant: Anything else you want the lawyer to know before I connect you?

That's it. The insurance is United Healthcare and I'm on an HMO.

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Answered in 1 minute by:
10/28/2017
Dwayne B.
Dwayne B., Attorney
Category: Legal
Satisfied Customers: 34,387
Experience: Began practicing law in 1992
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Hello and thank you for contacting us. This is Dwayne B. and I’m an expert here and looking forward to assisting you today.

Please allow me several minutes to read your facts and type my response both initially and when you add a follow up question or add facts. Please don't ask "are you there", "where is my answer", etc., since when you post it can erase what I am working on. If we are having a conversation unless I tell you I am going offline, I will be here but I may be doing research.

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Do you know whether your insurance has a maximum number of speech therapy sessions per year, regardless of the situation?

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Customer reply replied 3 months ago
I don't know that. One other thing to mention: since my son isn't 3 yet he can't be officially diagnosed. The speech therapist suspects Apraxia but since children are still developing, my son can't be diagnosed until he's 3. And the insurance company says he's not eligible because he doesn't have autism or a history of developmental delays. But he's 2! Of course he doesn't have a long history but his last two checkups were consistent. Seems like the system is rigged.

It may very well be rigged. Unfortunately, health insurance is a contract and you agree to the terms of the contract when you sign up for it.

I'd suggest you take the policy to a local lawyer that does Consumer Law or Civil Litigation and let them review the contract plus any paperwork you received from the insurance company. My guess is that they are telling you the truth about what your policy says but I've seen a lot of cases, and sued a lot of times, when the insurance company just chose to ignore their duties.

In addition, the lawyer may be able to find an expert who is willing to enter a diagnosis pursuant to the terms of the policy (perhaps by making it a temporary diagnosis) which enables you to get benefits while still not requiring the expert to stick their neck out too far.

THose are the steps to take if you want to get a resolution to the case which is most likely to be in your favor. It will either allow you to know for sure they are doing what they are allowed to do, are not doing what they should do, or how to force their hand and force them to do what they should do. The cost for a local lawyer to do this evaluation should be minimal when compared to what might be gained or lost.

If your question has been answered then I'd offer my best wishes to you and ask that you please not forget to leave a 5 Star Positive Rating so I receive credit for my work. Also please consider clicking "BONUS" as a nice way of saying "thanks" for a job well done, although this is neither required nor expected. Of course, please feel free to ask any follow-up questions in this thread. I want to be sure all of your questions are answered.

Dwayne B.
Dwayne B., Attorney
Category: Legal
Satisfied Customers: 34,387
Experience: Began practicing law in 1992
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