If you have a child with autism, you know how complicated it can be to access and pay for the health care needs of your child. Individuals suffering from Autism Spectrum Disorders (ASD) have difficulties with verbal and nonverbal communication, social interactions, and have narrowed and repetitive interests and activities. There’s no cure for autism, but the condition is treatable. Most health professionals emphasize the importance of early intervention treatment programs. Treatment options may include complementary and alternative medicine, educational and behavioral interventions, and medications or dietary changes to relieve or manage the symptoms of autism. These treatment options can be costly.

On an annual basis, it costs about $17,000 or more to care for a child with autism compared to a child who does not have autism, according to the Centers for Disease Control (CDC). In addition, the cost can increase to over $21,000 more per year if the child has a severe case of ASD. Costs include therapy, education, health care, caregiver time, and family-coordinated services.

Things could get much worse and more depressing if the health care insurance company says it won’t cover treatment. The insurance company is supposed to be on your side and to pay out the benefits, but there are times when health insurers will not only make things harder by denying an autism insurance claim but be out rightly wrong in its actions. An insurance claim denial is a real problem. Health insurers will almost always find a way to keep the money in their pockets by denying insurance claims. Reasons like fraud, billing code errors, exclusions, missed premium payment, or misinterpretation on an application would be given to the claimant.

In such cases, claimants may feel helpless and at the mercy of the insurance company. But you shouldn’t. Any autism insurance denial should be questioned. It is not always easy to claim the money. The insurance giants usually bank on the fact that most policyholders do not know the law and that they’ll simply give up after receiving a denial letter. Similarly, they don’t expect that you will fight the denial. All you need to do is call up a law firm that’s knowledgeable and experienced in fighting claim denials.

Autism Insurance Denials Attorney

Understanding what a health insurance plan does or doesn’t can be overwhelming and confusing. Families with autistic children face additional difficulty when their health insurers wrongfully deny coverage for important and medically necessary treatments. The autism insurance denial lawyers at Stop Health Insurance Denial help families obtain coverage for treatments from their health plans and health insurers.

You may feel like your child’s ability to lead a normal life has been taken away when a health insurer denies coverage. We’ve seen how dooming, intimidating, and frustrating a denial can feel through our clients. But what you should keep in mind is that denying coverage is just part of the day-to-day business for insurance companies. If you’ve been denied coverage for autism treatments, including occupational therapy, speech therapy, and ABA, contact us today. We’re seasoned attorneys with extensive experience working with families affected by autism across the nation and are committed to helping you get the benefits you need and deserve. Stop Health Insurance Denials is always ready to help.

Denials for Applied Behavior Analysis (“ABA”) Therapy

The Autism Insurance Act requires health insurers to provide coverage for a child’s therapy- such as Applied Behavior Analysis (ABA) - to the same extent they cover other physical illnesses. While ABA therapy is proven to improve the lives of autistic children, many health insurers violate the law by:

  • Not including ABA providers in its network
  • Denying coverage on the basis that ABA is social skills training/therapy or service for behavioral problems or learning disabilities
  • Claiming that ABA is not medically necessary
  • Denying coverage by claiming that ABA providers are not licensed and that autism insurance benefits are only available for licensed provider
  • Denying coverage by claiming that ABA is educational or experimental

Your coverage may not be denied based exclusively on the number of hours of habilitative services that are therapeutic and meant to enhance the child’s ability to function. Also, the insurer may be required to authorize additional hours as recommended by the healthcare provider, provided that the services are medically necessary. Payments for habilitative services are in most cases limited to service providers who are certified, licensed, or authorized.

Common Reasons Health Insurance Companies Give for Denying Coverage

There are literally hundreds of tactics and reasons that health insurers might deny payment for a healthcare service. Some are relatively easy to fix while others are more tactful and difficult to address. Here’s why your autism insurance claim may be denied:

  • The requested service is investigational or experimental
  • You don’t really need the requested service
  • The service or treatment is not medically necessary
  • The benefit isn’t offered under your plan
  • Your child received therapy services from a facility of health provider that is not approved in your plan’s network.
  • You’re no longer enrolled or eligible to be enrolled
  • Your health plan is revoked or canceled because you gave incomplete or false information when you fill in the application forms
  • Insufficient information provided with the pre-authorization request or the claim

Your Right to Appeal an Autism Therapy Insurance Denial

Health insurance coverage can be an invaluable resource for families with autistic children because it makes the often high-frequency and high-cost treatments for their children more affordable. But if your insurer denies your claim, you have the right to appeal and ask your insurance company reconsider its decision. Your insurance company has to tell you why your coverage has been denied or why your coverage has been canceled. They also have to let you know how you can dispute their decision and within what amount of time. There are two ways to appeal an autism therapy insurance denial:

Internal Appeal

When your insurer denies your insurance coverage, they must notify you in writing and give detailed reasons within 72 hours for urgent care cases, within 30 days if you want coverage for medical services already receive or within 15 days if you are looking for prior authorization for treatment. To file an appeal, you need to submit all forms required by the insurance company and submit any additional information that you think is necessary and would like the insurance company to consider. An experienced autism denial attorney can help you with this process. At Stop Health Insurance Denial, we can work with you and your child’s therapist to assist in the analysis, evaluation, development, and submission of persuasive and credible medical evidence. We can as well gather full details if your child’s situation, review the policy and laws that apply, and use the facts to write a successful appeal letter. The goal of our team is to ensure that you receive the benefits to which your child or is entitled.

It is worth keeping in mind the fact that the internal appeal must be filed within 6 months (180 days) of receiving the denial notice. To improve chances of your appeal being successful, it is paramount to keep copies of all information related the denial and the claim. This includes information you provide to your insurance company as well as information that your insurance company provides such as:

  • Copies of any letters or forms you are required to sign
  • Notes and dates from any conversation you have with your insurer
  • The Explanation of Benefits letters or forms showing what services or payment you were denied
  • Any additional information you sent to your insurance company like a letter from your doctor
  • A copy of the request for an internal appeal
  • Keep your original documents but be sure to submit all the relevant copies to your insurer

You must file the internal appeal within 60 days if your appeal is for a service you have already received and within 30 days if you are filing for a service that is yet to be received. At the end of the end of the internal appeals process, the insurer should provide you with a written decision. You can ask for an external review if you are still denied the service or payment for service even after you have filed an appeal.

Once the internal appeal has been filed, the record is locked. This means that you will not have any other chance to submit additional information to prove your case. If your insurer still upholds its decision to deny your claim and you decide to request an external review or file a lawsuit, then the evidence you submit may be limited. The independent third party or court will use the records as the evidentiary basis to determine whether or not your autism insurance benefits should have been paid. If you never included the best evidence when appealing the insurer’s decision, chances are that they will never be used in your case. As such, it is important to hire an attorney to help you write your appeal letter. An experienced autism therapy insurance attorney knows the ins and outs of the law and how to best collect and present the best evidence to support your claim. This can help improve the likelihood that your child’s health care needs will be catered for by your insurer. In some cases- such as when your child is in urgent need of medical care- it may be important to just file a lawsuit than file an appeal and then take your case through an external review if your claim is still denied.

External Review

You can take your appeal to an independent third-party for review through what is referred to as external review. When your case gets to this stage, it means that your insurer no longer gets the final say over whether or not to pay a claim. You must file a written request within 60 days of the date that your insurance carrier sent the final decision. The notice you receive should tell you the amount of time you have to make your request. Once you have submitted the request, an independent third party either decides in your favor or upholds your insurer’s decision. The external reviewer’s decision is final and your insurance carrier is obligated by law to accept it. This means that the insurer should make the payments if the external reviewer reverses the denial. External reviews are typically decided within 60 days after the request was received.

Denials that can go to external review include those that involve:

  • a determination that treatment is investigational or experimental
  • medical judgment where you or the therapist may disagree with the health insurance plan
  • cancelation of coverage on the basis that you gave incomplete or false information when you applied for the health insurance plan

Insurance companies are required to fully take part in an external review process that meets the consumer protection standards. Your state may have an external review process but it doesn’t, you can file your request with the federal governments Department of Health and Human Services (HHS). The attorneys at Stop Health Insurance Denial can advise you concerning your rights under the federal and state laws.

Bringing a Lawsuit Against Your Insurer

If the decision made at the external review stage is still unsatisfactory or time is of the essence, you’ll be left with the option of seeking justice in the courtroom. Consulting with a seasoned autism insurance denial attorney is necessary at this time. When you come to us and explain the details involving your claim being denied, we can take it from there and help you develop a strong case that may help you get the coverage you need to take ensure your child’s health care needs are being met. To file a solid lawsuit, you should have your health insurance policy, documents of the insurer’s denials of your claim, a written log of your communication with the insurer, and a detailed and complete set of documents used and received during the internal appeals and external review processes.

There are also other key points that you should know to improve your chances of winning a lawsuit or obtaining a satisfactory settlement. One of the main ones is the fact that your insurance company may decide to send back your premiums while asking for a release. However, you shouldn’t sign any document without the guidance of a lawyer. Once your lawsuit has been filed, all documents and communications from the insurer must be reviewed by your attorney.

You may as well bring a bad faith insurance claim against your insurer for:

  • Declining a claim or refusing to settle
  • Failure to investigate
  • Failure to promptly respond to your claim

Bad faith insurance lawsuits usually defend the decisions of the treating doctors or ABA therapists over that of the insurer. These are really strong lawsuits because a medical condition could worsen following the denial. Also, a policyholder is left with a big whopping medical bill after the treatment is done but not covered. There are consequential damages and emotional distress that may result and juries may be outrages when they see a person with autism and needs treatment or necessary therapy didn’t get it because the insurer wants to make a profit. In a bad faith insurance claim, the insurance company bears the burden of proving that it acted appropriately.

If the insurer ignored your claim, acted unreasonably or engaged in other forms of bad faith insurance practices, the insurer can be sanctioned. You can be compensated for pain and suffering, emotional distress, financial expenses, attorney’s fees and punitive damages in the case of a successful bad faith lawsuit. Chances for getting a settlement before trial are also high. Insurance companies may decide to cover the treatment and ask for confidentiality because they realize that such cases are often explosive with the press and juries.

Finding an Autism Insurance Denial Attorney Near Me

While it may seem hopeless to take on a big insurance company when your legitimate autism insurance claim has been denied, retaining the services of a seasoned health insurance attorney can make the impossible- possible. A law firm that solely practices in this area of law can be a great resource. The attorneys understand how insurance companies operate and the tactic they use to delay, deny or unfairly pay benefits for less than they’re worth. But the best thing is that a health insurer’s autism therapy denial is not the last word. Policyholders do have options and an experienced attorney can help them fight back and recover what is rightfully theirs. At Stop Health Insurance Denial, our attorneys can:

  • thoroughly review your health insurance policy and determine the coverage you are entitled to
  • review your insurer’s denial letter
  • investigate your claim, doctors recommendations, and medical records
  • collect interviews from your care provider
  • file an internal appeal with the insurance company or an external appeal with your state’s regulatory body
  • file a bad faith insurance lawsuit,
  • and more

We help you file an appeal and negotiate the settlement with your insurer, and if their decision is still unsatisfactory, we can take them to court and seek a legal resolution. We’re committed to fighting for clients across the United States and seeing to it that health insurers honor their promise and provide the needed coverage. If you have been denied autism therapy coverage by any health insurance company in the U.S., for ABA services for your young or adult child who suffers from Pervasive Developmental Disorder or Autism Asperger Syndrome, contact Stop Health Insurance Denial today at 310-695-5241 for a free case evaluation. Don’t be a victim twice!