Health Insurance denied

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Our son has borderline Aspergers. We are self employed and can't get health insurance for him! He doesn't need autism therapy or his counseling covered. He is healthy, but we were still denied. Do any of you have advice on this? Thanks so much

back health care reform. if it goes through, no one will be able to be denied coverage starting in 2014.

Are you sure your son actually has AS? Or does he have NVLD? The latter is not considered a medical or psychiatric condition.

Is the diagnosis iron-clad? Mine is signed by a psychiatrist. But all kinds of counselors and psychologists think they are qualified to diagnose Asperger's. They are not, because Asperger's is defined in the DSM, which is for psychiatrists. So you may want to consider the validity of the diagnosis.

Also - please don't use the word "borderline" - there's no such thing as borderline Asperger's, but the word "borderline" terrifies almost everybody. In itself it might be the reason for refusal.

I got insurance for myself, with Asperger's at age 61, with one of those companies that advertise on TV. The basic version, where they turn nobody down, is good coverage (includes dental and psychologists). You would insure yourself and your son as a dependent. It costs me about $100/mo. I tried to get the higher coverage (meds) but they turned me down because I'm already taking a fortune worth of meds - which your son is probably not, so you could get the better coverage.

Best of luck!

p.s. I'm in Canada, so cost of meds is secondary. Structures will be different depending where you are.

Have you tried with more than 1 insurance company?

What exactly do you mean by "can't get health insurance for him"? Have you tried to get him covered and been denied because the ins company says it is a pre-existing condition or something? Has he been diagnosed but your existing insurance denied the claim? The possible solutions depend on what you mean specifically

This is the insurance company that covered me - with their "Affinity Markets"

http://www1.manulife.com/can/affinity/a ... c/Homepage

I don't know if this is Canadian or USA site, but maybe it'll be a help somehow.

I think that in the U.S., insurance companies can no longer deny coverage to a child based upon a pre-existing condition. However, they can put a rider on the policy such that insurance for a child with a preexisting condition will cost a lot more.

We are self-employed also.

Currently, my son with classic autism is insured through the state high risk pool as my dependent. (I'm uninsurable. even though I'm in good health, don't smoke, take care of myself, etc., because I have a history of epilepsy and Crohn's Disease.) It is not cheap, but you can pay less for it if you choose a high deductible policy or qualify for a reduced rate based on income.

We called Assurant Health ( see website if you are interested ,http://www.assuranthealth.com/corp/ah/AHHome.htm ) and were basically told that an individual policy for my son would be more expensive than what he already has through the state high risk pool due to an autism rider increasing the premium. However, if he is placed on the policy that my younger son and husband are already on, there would still be a rider, but the policy would be a little cheaper.

Of note, if your child is currently uninsured, you might have to apply and then wait a year before you would actually be eligible for benefits.

Here is a list of states with high risk pools for people who are not eligible for Medicare or Medicaid but cannot get health coverage..:

http://www.naschip.org/states_pools.htm

There are many professional trade groups that offer "group" medical plans to all their members. Research the trade groups and see which ones offer group insurance options, then see if you can meet any of the requirements to join (it isn't always obvious, some friends of mine joined an Asian business association even though neither were Asian). Once in, after a few months waiting period, you get group coverage, which is usually fairly automatic. That was how we got the full family covered when my husband and I were both self-employed.

Once health reform is fully phased in such shenanigans should no longer be necessary but until that happens, it's how the game is played.

Unfortunately the private health insurance can still get away with this. I hope that they can do something about it.
Also I have never heard the term "borderline" Asperger's....either you have Aspergers or you dont. I do understand that people can be more affected but where did this borderline thing come from and what does this mean?

Thanks for all the replies. We may have to use the state risk pool. I used the term borderline because we have been told different things by different doctors. They all say he is on the spectrum but some say mild aspergers and some say PDD-NOS.

I don't think that type of diagnosis would carry much weight as an "official Asperger's Syndrome diagnosis". As far as I understand it, an "official diagnosis" today can only be determined by an assessment designed to diagnosis autistic spectrum disorders. A person who is "on the spectrum" can either meet the criteria for AS, PDD-NOS, ASD, or NVLD depending on their particular strengths and weaknesses. There is little, if any difference between AS and NVLD aside from a few hotly contested things, and the fact that NVLD is consider a learning disorder and not something coverable or relevant to insurance companies.

It sounds to me that you are insisting to the insurance companies that your son has something that professionals don't all agree that he has and for which there is no formal diagnosis undisputedly attesting to the fact that he has it.

That makes no sense to me. If no agreed upon formal diagnosis exists and he might very well have something classified as a learning disability instead, why tell them he has AS?

whether they call it aspergers or pdd-nos, doesnt really matter, its all autism.

some states offer a waiver program where you can get medicaid coverage even if you are over the income limit, or can purchase coverage for children if over the limit but within a certain income range. your local dhs office could give you info on whether you qualify for those programs.

With respect to health insurance companies, it does matter. At a health insurance company, a diagnosis of something is entered into the system using a diagnostic code which is used during the underwriting process to determine your coverage.

I have a health condition which used to be coded with a diagnostic code which was a sub-category of a similar yet entirely different condition with a different cause and different (much more dire) prognosis. This had caused others with the same condition that I have to be denied insurance, or offered insurance at rates exceeding $600 per month.

A group of advocates successfully lobbied to have the condition coded under it's own category where it rightfully belonged and this eliminated the issue of those with the condition being denied insurance or charged such high rates.

In my very limited experience; the Pdoc originally used the diagnostic code for developmental delay and the insurance company refused to cover OT under that code. I had the Pdoc change it to autism (she agreed that he fit the diagnostic criteria) and resubmitted the claim and, viola, they covered the OT services. Developmental delay was not an accurate diagnosis for DS anyway. At the time I didn't really care what the Pdoc records said as long as it would get us coverage. Of course this is the VERY abbreviated version of how I got there.

How old is your child? He is probably eligible for services via either your local school district (I'm assuming you're in the US - so, any child under 18) or by your local Department Of Health. Many states also have a child-specific health insurance you can purchase for low or no cost.

Google your state's Department of Human Services and make a few phone calls to see if you can get coverage that way.