Precedent for covering a treatment

I am not sure where else to turn, so hopefully someone here can help.

My daughter has been receiving occupational therapy for several years, due to her Sensory Processing Disorder. Since 10/2016, she has been covered under my insurance through my employer.

Our provider contacted us this week to tell us that they had started having problems with claims being denied in 9/2020. They did not tell us until now due to the length of time the insurance takes to pay.

My employer is self insured, but uses a ‘benefits administrator ‘ to administer the plan. I contacted our HR Manager to ask her about the issues with the claims. She had apparently already been contacted by the insurance.

I was then told that my daughter’s treatment was not covered for her OT unless it was for ADD or ADHD. They are claiming that this was an oversight & it should never have been covered. Whaaat!? The insurance is working out how to pay what is currently outstanding, but, will not cover further treatment.

Frustrated does not even describe how I feel. After talking to the provider (I had to put a hold on future appointments), they mentioned that the insurance may have already set a precedent for covering this. I do plan on filing an appeal once I am certain that outstanding claims are being paid, but I am wondering if anyone here has had a similar experience. Any help/advice would be greatly appreciated. Thanks!

submitted by /u/dawoof6
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I am not sure where else to turn, so hopefully someone here can help. My daughter has been receiving occupational therapy for several years, due to her Sensory Processing Disorder. Since 10/2016, she has been covered under my insurance through my employer. Our provider contacted us this week to tell us that they had started having problems with claims being denied in 9/2020. They did not tell us until now due to the length of time the insurance takes to pay. My employer is self insured, but uses a ‘benefits administrator ‘ to administer the plan. I contacted our HR Manager to ask her about the issues with the claims. She had apparently already been contacted by the insurance. I was then told that my daughter’s treatment was not covered for her OT unless it was for ADD or ADHD. They are claiming that this was an oversight & it should never have been covered. Whaaat!? The insurance is working out how to pay what is currently outstanding, but, will not cover further treatment. Frustrated does not even describe how I feel. After talking to the provider (I had to put a hold on future appointments), they mentioned that the insurance may have already set a precedent for covering this. I do plan on filing an appeal once I am certain that outstanding claims are being paid, but I am wondering if anyone here has had a similar experience. Any help/advice would be greatly appreciated. Thanks!
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