Some New Wins!

November 23, 2011

We recently won two more very significant appeals of the denial of ABA therapy under self-funded insurance plans.

In the first case, the insurer had a very clear exclusion barring coverage for ABA therapy.  The exclusion was stated in a self-funded plan covering an New York-based employer.  After submitting the claims for the client, receiving the denials, going through the appeal process, we finally wound up submitting an appeal directly to the employer’s insurance committee.   In that appeal letter, we pointed out some ambiguities in the coverage and in the exclusion, explained why ABA therapy is medically necessary to treat autism, backed up our assertion up with clinical/research and documents supporting the fact that the therapy had been effective in treating our client’s child.  Despite the exclusion, we won the appeal – the employer directed the insurer to pay all of the clients ABA therapy claims, which exceed 50K in therapy costs!

In the second case self-funded case, the employer was based in Illinois.  The client/employee had previously submitted ABA therapy claims to the insurer under a psychotherapy code and the claims were reimbursed/paid.  The client later became concerned about whether the insurance payments were erroneous because the insurer later insisted during a telephone call that the policy excluded coverage for ABA therapy.  Upon review of the plan documents, we noted that no such exclusion was included in the plan.  The client pointed out the issue and   asked for clarification from his human resources department.  He was advised that the proper coding and related issue of reimbursement for ABA therapy under a psychotherapy code was in a “gray” area.  At our encouragement, the employee asked and was allowed to submit a letter to his employer in support of coverage explaining why ABA therapy was medically necessary to treat children on the autism therapy and why the terms of the policy would compel coverage for such therapy.  We drafted the letter for the employee, who submitted it with supporting documentation.  After considering our input, the employer not only agreed to cover the employee’s past ABA therapy claims (previously submitted as psychotherapy), the employer amended its plan to cover the company’s other employees for ABA therapy, up to a 36K limit per year.  What a fabulous victory!  

Needless to say are thrilled with both results!

The Take Away:  Push back and bring appeals on self-funded plans even when the insurer says there is an exclusion or denies coverage.


September 29, 2010

I have decided to start posting on some of the Firm’s cases/appeals, leaving out identifying information.   I hope this will encourage people to pursue their claims even when an insurer initially denies a coverage obligation.

Recently, we won a few appeals. The first appeal involved a situation where an insurer denied its obligation to pay for ABA therapy provided to an autistic child back in 2008 (prior to the enactment of the New Jersey Autism Insurance Act).  The claims were denied because they were submitted after the time had expired to submit out of network claims. The appeal asserted that the claims were submitted late because the insurer erroneously advised the insured that ABA was not covered under the policy, even though the insurer had an obligation to cover ABA therapy under the New Jersey Mental Health Parity Act and the Micheletti case. A short appeal letter went in on the insured’s behalf.  The insurer reversed its denial of coverage! The claims will amount to approximately 50K to 60K in reimbursements for the insured.

The second appeal involved a denial of speech coverage for an autistic child which was contrary New Jersey law under the Mental Health Parity Act and the Autism Insurance Act. A short appeal letter again reversed the insurer’s denial of coverage. The child now has coverage for the speech therapy that she needs.

The third appeal involved our convincing an insurer to overturn its decision to deny coverage for in-patient treatment of a child suffering from various mental health conditions and severe paranoid delusions. Incredibly, the insurer denied coverage despite overwhelming evidence that the child was in great need of 24:7 supervision and intense therapy.   After almost a year of fighting, we won our appeal.

Advice to insureds: Support your claims with medical evidence, be persistent and organized. Adhere to the appeal process and timelines.  Most of all, don’t give up hope.

Speaking Engagement

February 10, 2010

Hello again,

I hope everyone is doing well and staying warm in this nor’easter mother nature has given us.

I wanted to inform you of a future speaking engagement that I and Yvonne, my paralegal for the firm (see biography of Yvonne in the links box), will be presenting at.

“The Young Child Expo and Conference” is taking place at the Hilton, New York, for a two day conference from April 9th-10th 2010. The website has been recently updated providing registration fees, an opportunity to register online, a schedule of the two day conference, a list of the speakers and more.

Like the website says the 2010 Young Child Expo & Conference brings together top leaders to provide the latest information about essential topics in early childhood development. Early childhood professionals and parents will learn also about services, resources, and products to help all children reach their full potential. In one unique event, this conference integrates learning about typically developing children as well as those with special needs, including autism.”

The conference benefits a lot of people. The following should consider attending; Teachers, Social Workers, Occupational Therapists, Physicians, Administrators, Case Managers, Parents, Grandparents, Caretakers, Psychologists, Speech and Physical Therapists, Nurses, Service Coordinator, Foster Care Provider and Students.  If you know others who are in  any of these categories, please pass along the information of this conference.

Here is the official link to the conference:

Hope to see everyone there!

Attachments Posted

January 27, 2010

Today I have posted attachments that you can access from the Information For You! box that is underneath my picture and bio.

The first attachment is a summary of the New Jersey’s Autism Insurance Bill which I drafted for an ABA provider’s newsletter.    The Autism Insurance Bill was signed into law this past Summer and the attached answers a few questions about the Bill and how it might apply to your insurance policy. Please take a look and feel free to ask any question.

I am also attaching a recent Bulletin issued by the New Jersey Department of Insurance directing insurers on how they should implement the terms of the New Jersey Autism Insurance Bill.

I have further attached a Firm handout on how to use the New Jersey Mental Health Parity Act as a sword to obtain health insurance for your autistic child.


January 8, 2010

Hello All:

I started this blog as a venue for people to reach out and ask me questions about how they might obtain health insurance coverage when an insurance company has already denied a claim, or even prior to making a claim.

I am a veteran insurance coverage lawyer with a legal practice in New Jersey (licensed in New Jersey and New York).  Bouer Law LLC, operates out of Princeton, New Jersey (609-924-3990).

The Firm was created to provide coverage, claims and coding advice to clients from all over the United States.

Some Background:

For the last 12 years or so, I worked at New Jersey’s largest law firms representing insurance companies in coverage litigations.   For a time, I also worked in-house and was coverage counsel for a group of insurance companies.

I started representing policyholders against insurers when I was forced to fight (successfully) for health insurance coverage for a family member and then, a gravely ill friend.

I realized after these fights that most individual policyholders simply did not have the tools to fight for insurance coverage and win.   And so, I opened my law practice to respond to this need.

What We Do:

The Firm helps families with children on the autism spectrum obtain health insurance coverage for autism-related therapies.

The Firm also represents many other clients who need help obtaining coverage for other mental health and medical conditions, surgeries and procedures.

We even have an insurance coding professional on board who helps clients obtain preauthorizations, and prepares and submits claims to maximize the possibility that they will get paid without a fight/denial.

Ask the Lawyer:

I am down-to-earth and approachable and so, I created this Blog.

“Fire away!”  I  welcome your questions.