How do I find a real person at my insurance company?

March 25, 2009 9:55 AM

My young child has been diagnosed with an Autism Spectrum Disorder. I need some help, please, with getting insurance coverage for his treatment.

We are in Illinois and we are insured by Blue Cross Blue Shield of Illinois. We have our own policy - that is, we are self-employed and signed up on our own with Blue Cross. There is no HR department to assist with this. We live in the Chicago suburbs.

My son has been receiving speech and occupational therapy for about a year. All claims have been denied. This past December, he was formally diagnosed with an Autism Spectrum Disorder. Coincidentally in December, former governor Rod Blagojevich signed into law an Autism Bill that requires insurers to pay up to $36,000 a year in benefits for autism treatment.

Our claims are still being denied. We are not seeking out any sort of alternative treatment - we're going with the American Academy of Pediatrics recommendations, and all of our doctors and therapists are Blue Cross providers.

Our pediatrician has written a very compelling letter on our son's behalf, outlining why it is so critical for him to continue treatment. She has advised us to find the name of an actual person at Blue Cross to send this letter to, rather than just sending it to the "Appeals Department".

Can anyone help in finding such a name? It doesn't even have to be exactly the right person ... just an actual person who works there and can direct the letter to the right place. We will send it by registered mail. When I call and ask for the name of someone to send it to, they just tell me to send it to the appeals department. I feel like it's part of the game they play, to keep us in the dark about what we're entitled to and to make it really difficult to move forward.

I have no "google fu" so please don't jump all over me if the answer to this is easy to find. I've looked and called and asked all of our service providers and had no luck. I'm just hanging on here, trying to get my son the help he needs and trying to figure out how to even begin paying for it.

So, if you have any advice on finding the right person, or even close to the right person to send this letter to, please advise. I would be most grateful. You may also reach me at [e-mail]. And thank you.

posted by anonymous to Health & Fitness (4 answers total)

The Consumerist turned up this contact information, current as of last September:

Raymond F. McCaskey
President and CEO
Blue Cross and Blue Shield of Illinois, Texas,
New Mexico and Oklahoma
300 East Randolph Street
Chicago, IL 60601-5099
Phone: [phone]
Fax: [phone]
Email: [e-mail]
Asst: Lynne Recupido
Phone: [phone]
Email: [e-mail]
posted by MonkeyToes at 10:08 AM on March 25, 2009

Unfortunately, it looks like that law will only take effect on policies that are issued or renewed after December 12, 2008. So, if you (for instance) signed a year-long policy last June, and the contract specifically excluded services for autism, you might be out of luck until you renew your policy next June.

What reason is Blue Cross giving you for the denial? (For instance, are they saying it's not a covered benefit, or are they saying it's not medically necessary?) If the money you're losing on this is substantial enough, you might want to consider hiring a lawyer who specializes in this sort of thing to go through the contract and fight the company on your behalf. Either way, though, there's definitely no harm in keeping up the appeals--they might reverse themselves if you can prove that the treatments are medically necessary and included within the scope of your insurance contract.

So, even if you find an actual person at Blue Cross to send this letter to, you should continue to use the formal appeal process--you're given specific rights under state law with regards to the appeals process, but you may well forfeit those rights if you don't follow the procedures laid out by the company to appeal each and every denial. Even though you don't have an HR department, there are resources to help you figure this out, particularly at the Illinois Division of Insurance. In fact, they have a toll-free number you can call and ask all sorts of questions about what your insurance company is required to do and what is covered under your contract. That number is [phone].
posted by iminurmefi at 11:11 AM on March 25, 2009

I have no Illinois specific information, but keep pecking away a BCBS. Whenever you send the letter, include a photo of your child.

There are also lots of family reimbursement programs that help families pay for services and buy special tools for kids with ASD. Usually there are time limits on purchases/billing, but in your case, after the insurance took so long to get sorted out, they might make an exception.

A quick search for Autism Advocacy in Illinois brought up this:
Zena Naiditch
Executive Director
Illinois Equip for Equality, Inc.
11 E. Adams, Suite 1200
Chicago, Illinois 60603

[phone] Voice/TDD
FAX [phone]
E-Mail - [e-mail]

I wish you all the best! We have an almost 5 year old son with ASD and are very, very thankful that our County and School District pay for all his services. Monroe County/Rochester NY in case anyone is considering moving!
posted by Mrs_Eep at 12:40 PM on March 25, 2009

I just wanted to mention that between early/mid 2007 and September 2008, I was fighting with Aetna to get treatment for my chronic illness covered. They refused because they insisted that it was a pre-existing condition and I needed to be covered for 6 months before they'd start paying, unless I'd been covered by another insurance company before switching to Aetna. Which I had been, so I argued that they ought to pay. Except, Aetna rebutted, I was still covered by that other company (SWICA) primarily, so Aetna would only cover my care if SWICA rejected my claim as primary insurance coverage. They then ignored several letters I sent attesting that SWICA is only my emergency travel coverage.

Finally, in September, after a year and a half of this back and forth, I sent a very polite e-mail through an intermediary explaining that in one week my father would be visiting me, and we would be calling Aetna directly. If we were not able to resolve everything entirely in that one phone call, then we would pursue legal action.

Magically, the entire tangled problem was resolved in three days. Within the next couple of months, Aetna reimbursed me all the money they owed me - more than $700. Oddly, it came in two checks: one for $3 and one for the rest. Very strange.

And the moral of this story is: insurance companies are scared of lawyers. If you go that direction, do be prepared to back words with action - have an actual lawyer in your pocket, first.

Best of luck! Hope you can get your kid the care he needs.
posted by bettafish at 5:13 PM on March 25, 2009