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One battle in the war against health-insurer insensitivity

By David Lazarus for the LA Times

It would be so easy for health insurers to avoid ill will if they’d just listen to what customers are saying and do their best to respond in a reasonable fashion.

Unfortunately, that’s just not how the industry seems to be programmed.

Kevin Roberts, 36, has been battling insurance-industry insensitivity since last year on behalf of his 6-year-old daughter, Aubrey, who has autism.

What should have been a relatively simple matter has ballooned into complaints to the California Department of Managed Health Care, failed attempts at arbitration and a seeming reluctance on the part of Roberts’ insurer, Aetna, to simply sit down and hash things out.

“We’re basically in limbo,” Roberts told me. “All we’ve wanted is for them to take care of treatment that’s covered by our insurance policy. But they won’t do it.”

California passed a law in October requiring insurers to cover behavioral therapy for autistic kids. But for many families, it can be a long, hard struggle to cover clinic bills, which can total as much as $50,000 annually.

Since the beginning of 2011, the Department of Managed Health Care has received almost 600 complaints against the seven largest health plans over problems with authorizing autism-related treatments.

Kaiser, with about 7 million enrollees, was the subject of the most complaints, 317. Blue Shield, with roughly 2.5 million enrollees, had 69 complaints. Aetna, with slightly more than 800,000 enrollees, had nine.

Roberts’ troubles began in February 2011 when a neurologist in Aetna’s healthcare provider network prescribed occupational therapy for Aubrey.

This is a form of treatment that focuses on developing motor skills. It’s been found to calm autistic kids and help them focus on learning other abilities.

Roberts said his Aetna policy covers 20 visits a year to an in-network occupational therapist. The insurer approved treatment at a clinic near the family’s Chino home called United Therapy Network.

But when Roberts and his daughter visited the clinic, they were told that the type of occupational therapy Aubrey required — known as sensory integration therapy — wasn’t available at the facility. They were advised to seek another referral from Aetna.

The insurer responded by instructing Roberts to take his daughter back to United Therapy Network. Roberts sent in a letter explaining, again, that the clinic didn’t provide the therapy Aubrey needed. He, again, requested another referral.

Aetna insisted that Roberts had to take his daughter to United Therapy Network.

He returned to the clinic and obtained a letter attesting to the fact that the facility couldn’t help. He sent it to Aetna with his third request for a referral elsewhere.

Aetna once again told Roberts he had to take his daughter to United Therapy Network.

State investigators would later conclude that Aetna “either ignored or disregarded” Roberts’ repeated efforts to follow the insurer’s own referral process. It would seem like a Monty Python sketch if it wasn’t such a serious matter.

While months were passing with this insane correspondence, Roberts said he learned of another clinic, Big Fun Physical Therapy, that was only five minutes away from his house. It offered the treatment Aubrey required, and as luck would have it, there was a slot open.

So even though he was getting nowhere with Aetna, Roberts did what any concerned parent would do: He started taking his daughter to the facility where she could be helped. Each weekly visit cost $120.

In December, Roberts filed a complaint with the state Department of Managed Health Care over Aetna’s apparent refusal to cover the therapy. He then filed a request for arbitration with the American Arbitration Assn., according to the terms of his Aetna contract.

State officials determined in March that “there was no effort” by Aetna to contact United Therapy Network and determine whether it could provide the needed therapy. They said the insurer’s actions “had the potential to significantly delay the treatment of a child with autism.”

The Department of Managed Health Care ordered Aetna to compensate Roberts for his past costs and to continue covering out-of-network treatment at Big Fun until the end of the year.

What did Aetna have to say? Nothing, according to Roberts.

The company also didn’t respond to a request from the arbitration group that it waive a provision of its contract limiting the amount of damages that can be awarded to customers, which the association said was not in keeping with its rules.

As a result of Aetna’s refusal to play ball, the arbitration group said it couldn’t handle the case.

Anjanette Coplin, an Aetna spokeswoman, told me by email that “we have resolved the benefits dispute with the Roberts family and all claims have been paid and will continue to be paid through Dec. 31, 2012.” This is in keeping with the order from state officials.

Coplin said Aetna “originally did not understand the nature of the dispute” because arbitrators hadn’t forwarded all necessary paperwork. She said Aetna was now ready to proceed with arbitration.

Asked why Roberts was repeatedly instructed to take his daughter to a facility that didn’t offer the needed therapy, Coplin suggested that Roberts didn’t correctly follow the referral process — a conclusion that state officials deemed “factually inaccurate.”

Aetna is now trying to come to terms with Big Fun so Aubrey can continue receiving treatment at the clinic, Coplin said. But she said negotiations have been stalled by the clinic’s insistence that all co-pays be waived.

Roberts said he was told by Big Fun that the actual hang-up was that Aetna was offering “substantially” lower fees than the clinic typically receives for treatment.

If no deal can be reached, he said, he may have to go to another in-network clinic Aetna referred him to — about a 90-minute drive away.

What’s so sad is that if someone at Aetna had simply picked up a phone and made one call to United Therapy Network and another to Big Fun, almost two years of hassles probably could have been avoided.

Instead, a family has faced months of needless uncertainty. And a 6-year-old girl still awaits a bureaucratic decision authorizing coverage of easily accessed treatment that could give her a chance at a more normal life.

It would be so easy for insurers to avoid ill will.

If that was something they actually cared about.

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