Aetna Insurance

It's been about a year since Daniel started therapy at St. Margaret Pediatric Rehab, and he has made tremendous progress. His therapists have done much more in only one year than the therapists in the public schools did in almost 2 full school years. A year ago, Aetna assured me that therapy would be covered for him, so we started him in therapy. Without our knowledge, someone at Aetna decided to stop covering his therapy in January. Additionally, we NEVER received a letter from them about that decision. When I called to find out what was going on with claims in June, they finally decided to tell me about that decision - over 5 months later! Because they gave me false information and failed to inform us of this decision, they decided to cover therapy through June 30.

We had a conference call with some of their reps, and we were told to mail and fax information to them regarding Daniel's medical condition, so that they could help us. Now, they are denying coverage stating that we don't have such coverage in our policy - something they should have told me a year ago. They admitted that they never took Daniel's medical information into consideration in their flat denial of our request. Needless to say, I filed a complaint with the Illinois Department of Insurance because Aetna has been misleading us for an entire year. Enough is enough!

Daniel sees a pediatrician and 3 pediatric specialists on a regular basis. All of his doctors and therapists agree that he is at risk for injury and regression if he does not receive treatment. He even has a documented history of injuries and emergency room visits for treatment prior to receiving therapy. You would think that Aetna would want to cover his therapy as a preventative measure. They're going to have to cover all claims if he gets hurt. To top that off, we were told that their "medical directors" are "family physicians." They don't have any pediatric expertise, and none of them are licensed pediatricians - nice! Seven pediatric professionals can't all be wrong!

Of course, we have also asked his doctors and therapists to do peer to peer reviews with them. When Daniel's speech therapist called yesterday, they refused to let her have a peer to peer review, and they told her that they don't have anything for her to do a peer to peer review on. Yet, we received an email confirming that a Level 1 appeal has been opened. Once again, they are contradicting themselves. I'm not surprised.

Last night, I combed through every bit of our insurance information, which it took over a year to get, and discovered that speech therapy is allowed for pervasive developmental disorders - something Daniel DOES have. That is mentioned in the notes from his first visit to his developmental pediatrician, which was faxed to Aetna. The information we have provides coverage for speech therapy for this disorder.

The fact that Aetna would deny a child with Daniel's disorder coverage, and ask me not think badly of them in our conference call, is puzzling to say the least! I'm quite sure that if this were one of their children, coverage would be provided, and they wouldn't have to go through this.

It's amazing how they contradict their own corporate mission statement in all of this - "We seek to achieve superior customer satisfaction through innovative products, comprehensive health and related benefits choices, effective service and easy-to-understand information. Our goals are: To give individuals and families affordable coverage choices, helpful service and information so they can make better-informed decisions to optimize their health and financial security. To respect and work effectively with doctors and hospitals by establishing efficient processes and providing prompt claims payments and useful information that helps them provide safe, cost-effective, high-quality health care." If they were truly dedicated to all that they say they are, they would take Daniel's medical needs into consideration and work with his family and his doctors to give him the high-quality health care he needs.