When talking about insurance coverage for substance abuse and mental illnesses, people often assume that the problem is limited to the poor. That assumption is way off the mark. Even for those families with “good” health insurance, coverage is far from easy to obtain.
In my own experience, when trying to obtain coverage for residential treatment, you are often told the treatment can be obtained on an outpatient basis. In our community, that treatment could be offered at a community hospital, could be available only a few days a week, and is hardly suitable for an adolescent who needs detox, medication, therapy, group therapy, education and stabilization which takes months and years not days and weeks.
In my experience, even when our child was hospitalized for mania, the insurance company said that three days was adequate, the hospital disagreed and put us in touch with the insurance commissioner who obtained 10 days of coverage. At that critical time, when our child was very sick, it gave us the opportunity to have a diagnosis, begin a form of treatment and begin to look for long term residential care to begin to deal with the substance abuse issues.
Families who are looking for treatment for substance abuse and mental illnesses are often at their wits’ end. Not only is the loved one ill, the entire family is traumatized. It’s exactly the time when insurances are most needed and making families fight for coverage at their most vulnerable time is unconscionable.
This kind of “rationing” of mental health treatment is routine. If your child had a physical ailment, I doubt the insurance company would have second guessed the health professionals as readily or as frequently as what you experienced. It is discriminatory, and it also makes poor economic sense, as inadequately treated mental health and substance abuse ailments go on to become increasingly life-threatening physical ailments, and then the insurance company will have to pay for that treatment.
Your story is about knowing how to challenge an insurance company – and you won! Many families don’t know how to do this – or simply would not win.
When our son needed treatment, a psychiatrist from his outpatient program called me at the time of discharge and told me that my son’s life could be endangered if we did not get him into long term residential care. We fought with the insurance company and got him admitted. Then after a mere 10 days, that program called and asked us – asked US !- where he was going after they discharged him. It turned out they only had authorization to keep him for 2 weeks!
We managed somehow to get an extension, so we could begin the search for a long term residential program. Finally we found one in Florida, flew him there, and paid for him to be there for 9 months. We financed this by taking out a home equity loan. Insurance claimed that we had exhausted his benefits; we could not find any basis on which to challenge that. He has over 7 years of sobriety now. What do families without our resources do to save their children’s lives, when the system lets them down as it let us down?
I need to clarify that we never got insurance coverage for our child’s inpatient treatment and almost everything except some counseling was out of pocket. That was the whole point of the story. Yes we had “good” insurance but the coverages were denied for the reasons I laid out.