One would think that the purpose of insurance would be to pay for the medical services to ameliorate the effects of a disease. However, insurance companies have taken the position that they will pay benefits only for those services which restore the patient to the position he had prior to the onset of the disease. This position does not make sense for children when it is the disease which prevents them from developing. The purpose of the services is to treat the effects of the disease to put the child where he would have been if he had not been inflicted with the diesease. For example, if the disease resulting in autism has prevented a child from acquiring language, he should get speech therapy to put him in the position where he would have been if he did not have autism. Insurance companies routinely deny speech therapy to children would would have spoken on the ground that they had not yet developed speech when they regressed into autism at age one.
Similarly, the New Jersey superior court stated:
"In addition, while the Handbook excludes treatment for development of a function or skill beyond that previously demonstrated, there is no definition of "development" or "developmental." Children are constantly developing. "Developmental" defines childhood. The words "restorative" and "non-restorative" when used in this context are also ambiguous and largely inapplicable to infants and young children. Every child is born with the potential to develop those skills necessary to life in society. Autistic children and other children afflicted with BBMIs are hindered from achieving that potential. The treatment for Jake can restore some of his potential. Even with the therapies described, Jake's prognosis is uncertain, but there is no claim that the treatment is futile. To the contrary, there is the expectation that, to some degree, he will share the skills and functions of more fortunate children, including his siblings."
Micheletti v. State Health Benefits Commission
Such a policy distinction is unjust and unreasonable.
position forces the cost from those who are paid to accept the risk to
the parents, charities and the State of Illinois. The legislature
should act to correct this practice. On October 23, 2006, Dr.
I. Rosenblatt, MD, testified before the joint hearing of the Health
Access and Availabillity and Developmental Disabilities and Mental
Committees of the Illinois House of Representatives. He informed
the legislature that when he was in Maryland, he worked with the
to pass a law which eliminates the habilitation/rehabilitation
for the developmental disabled. He urged the legislature to pass
a similar law in Illinois. He also noted that Maryland has
conducted the cost benefit analysis showing that the cost to a Plan is
minimal while the benefits to the State are huge.
The court in Jones-Kelley, below, noted "Taken to its logical conclusion, such a restrictive interpretation . . . would mean that no child who is born with a disability, could ever receive rehabilitative services."
March 2009 Update:
Habilitation Bill close to enactment. See text and description of Bill.
This Senate Bill 101 would take forward HB 1247, below,
which has lapsed. Both houses of the Illinois General Assembly
have passed the bill, and on February 11, 2009, it was sent to the new
governor as part of a package bill. Click the link above for
details of this proposed law.
Sec. 356z.9. Habilitative services for children.
(b) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 95th General Assembly must provide coverage for habilitative services for children under 19 years of age with a congenital or genetic defect existing at or from birth.
This bill is based on the Maryland Statute:
| § 15-835. "Habilitative services" and
system" defined; applicability; children under 19 years of age;
(a) "Habilitative services" and "managed care system" defined.-
(1) In this section the following words have the meanings indicated.
(2) (i) "Congenital or genetic birth defect" means a defect existing at or from birth, including a hereditary defect.
(ii) "Congenital or genetic birth defect" includes, but is not limited to:
2. cerebral palsy.
(4) "Managed care system" means a method that an insurer, a nonprofit health service plan, or a health maintenance organization uses to review and preauthorize a treatment plan that a health care practitioner develops for a covered person using a variety of cost containment methods to control utilization, quality, and claims.
(b) Applicability.- This section applies to:
(2) health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(2) An entity subject to this section is not required to provide reimbursement for habilitative services delivered through early intervention or school services.
(e) Adverse decision.- A determination by an entity subject to this section denying a request for habilitative services or denying payment for habilitative services on the grounds that a condition or disease is not a congenital or genetic birth defect is considered an "adverse decision" under § 15-10A-01 of this article.
[2000, ch. 92; 2002, ch. 382, § 1.]
On August 16, 2006, the State of New York enacted a law which states: