Private
Medical Insurance for Children with Disabilities
by
Herbert D. Hinkle, Esq. and Ira M. Fingles, Esq.
Herbert D. Hinkle
Law Office
2651 Main Street
Lawrenceville, New Jersey 08648
(609) 896-4200 or (215) 860-2100
Few things generate more concern for parents of children with disabilities
than making sure that their childâs medical needs are met. Many
children with disabilities are covered by private insurance policies.
Most group health
insurance plans provided as an employment benefit contain a provision
covering dependent children. Usually, coverage is provided until around
age eighteen, and sometimes coverage is extended to age twenty-two
or twenty-five if the child is disabled or a full-time student. Some
plans provide coverage for children with significant disabilities
without regard to their age. If coverage is not available through
a group health insurance plan, an individual insurance plan can be
purchased, but the premiums, deductibles, and co-payments under these
policies can be very high.
Many health insurance
policies contain restrictions on services such as speech therapy and
physical therapy if the services are needed as a result of a developmental
disability or if they are deemed to be ãeducationalä in
nature. However, it may be possible to appeal this type of limitation
if it is not described in the plan summary provided to the beneficiary.
Also, it remains unclear whether this type of limitation conflicts
with legislation requiring coverage of certain biologically-based
mental disorders such as autism.
All private insurance
policies contain some sort of appeals procedure. Usually, there are
several levels of "internal" review, which can range from
a simple paper review of the file to a full-blown hearing before a
panel of physicians and claims administrators. Both Pennsylvania and
New Jersey also provide for various forms of ãexternalä
reviews by independent agencies. In some circumstances, an action
can also be brought in court to compel coverage.
Copyright 2002
H.D. Hinkle. All rights reserved.
Mr. Hinkle maintains
a multi-state law practice with offices in Lawrenceville, Florham
Park, and Marlton, NJ, and Yardley, Pa. Mr. Hinkle and his colleagues
Ira Fingles, and Paul Prior lecture and write frequently on topics
of law, aging, and disability, and are available
to speak to groups in New Jersey and Pennsylvania
at no charge. Call (609) 896-4200.
