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My insurance company stopped paying while my son was in treatment

When the insurance company determines that care is no longer medically necessary and denies ongoing payment, patients have to make difficult financial decisions or are forced to stop in the middle of treatment.

By Virginia Holleman

Before my son entered residential treatment, I did my homework. I read my insurance plan’s explanation of benefits booklet to see if it provided coverage for substance use disorder treatment. I was pleased to find that it did! In fact, there was only one sentence devoted to coverage for substance use disorder, in contrast to the numerous pages devoted to coverage for medical and surgical services. So, I figured it was not a complex issue.

I turned out to be horribly wrong. Two days after my son was admitted into treatment, the director of the facility called me to tell me the insurance company was denying coverage. To say I was shocked is an understatement. The treatment facility told me I had limited options, all of which required me to pay thousands of dollars out of pocket to keep my son in treatment. I had to scramble and pull from many resources to keep him in treatment.

“I was stuck in the middle of an untenable catch-22 between the treatment facility and the insurance company, while my son was fighting for his life and my family was in crisis.”

The Problem

Historically, health plans have had significant discretion in selecting and applying medical necessity criteria. They have also resisted disclosing both their standards and explanations of how the criteria apply to a member’s specific condition, despite legal disclosure requirements.

These practices have made it difficult for patients to obtain affordable, life-saving care and to challenge health plan denials based on lack of medical necessity. Health plans may also violate the Parity Act if they use more restrictive medical necessity criteria for substance use disorder benefits, or apply it more restrictively, than the criteria used for or applied to comparable medical benefits.

The Solution

Require health plans to adopt medical necessity criteria that meets generally accepted standards of care. Enforce the Parity Act.

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