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It’s not easy to parent a child who suffers from mental, emotional, and physical disabilities. Navigating the medical and mental health system can be a job in itself. Top things off with a less than cooperative Employer provided group health plan and life can become more then just a little stressful.
Our beautiful 9-year-old daughter was placed for adoption with us at the age of 5. It’s been a long hard road filled with difficult parenting choices. I thought I knew everything after raising my older two children. Helping Makala has become the definition of Advocating for the best interest of a child. Thankfully, we have adoption assistance and Medicaid/state medical insurance because dealing with our private health insurance has become one of the most painful parts of our whole ordeal.
Makala was hospitalized in the children’s psychiatric unit for 5 days during the summer of 2004. It was just before the first grade and she was referred to attend a day treatment program. From January 2005 to March 2006 Makala attended full-time, five-days-a-week, all year with minimal breaks psychiatric day treatment. She returned to public school for the last few weeks of second grade.
This summer shortly before starting the third grade Makala had another 9-day stay in the children’s psychiatric hospital, where it was advised that she be placed in a sub-acute unit for several weeks. Our private insurance refused this referral and instead wanted to cover another 30-days of day treatment. We felt day treatment was not an option after having attended for 14-months why would another 30-days be helpful.
We had serious problems with safety arise again. In all of my life I have never felt so helpless and without a clue. Her behaviors have been frightening and non-stop. Just before the New Year we finally got our private insurance to cover admission to Sub Acute care. After a few days, our insurance, determined our daughter didn’t meet the criteria for continued treatment under the terms of our group health policy. The good thing is that Makala has the added adoption assistance and Medicaid/State medical coverage.
Our private insurance covered the first few days, and then during a review called a “Doctor to Doctor” our insurance refused to authorize any further time in the unit. Makala’s doctor in the psychiatric unit had recommended 30-60 days of residential treatment. Our insurance stated they would only cover if Makala was homicidal or suicidal.
Shortly after our insurance made this decision we received a certified letter in the main. The letter was from our group health provider and was titled: Initial Denial of Authorization. I knew it was coming and fully expected the letter. In the past I would have simply filed it–but, this time I decided to act on one paragraph which said:
“Your are entitled to receive free of charge, upon request, copies of all documents, records and other information relevant to your appeal for benefits.”
This time I decided to ask for all of the documents, so I called the phone number on the letter and requested all the documents our private group health insurance company used to determine our daughter didn’t need the care she is getting.
Be sure to stay tuned to the Insurance Blogs because you will never believe what I got in the documentation our health insurance company sent me!
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Blogs In This Series:
- Mental Health and Insurance: Advocating for Makala.
- Doctor-To-Doctor Review: Employer Provided Group Health Insurance
- Initial Denial of Authorization: The Letter.
- Copy of All Documents, Relevant to Your Appeal
Related Blogs:
- Understanding Employer Provided Group Health Insurance
- Primary and Secondary Health Insurance Coverage.
- Mental Health and Insurance: Statistics and Other Information
- Viewpoint: Health Insurance Dictates Treatment Options.
Glossary of Insurance Terms:
A | B | C | D | E | F | G | H | I | J-K | L | M | N | O | P | Q-R | S | T | U-V | W-Z
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