A Note About Insurance, Anorexia, and “Biologically Based” Disorders
November 25, 2008 by Kristina Chew, PhD
Filed under Health
In many states (such as Virginia), families of autistic children have been seeking legislation to provide for insurance coverage for treatment (usually ABA therapy) for their children. A recent decision involving insurance coverage for eating disorders in New Jersey might be of interest: As reported in today’s Star-Ledger, Horison—the state’s largest health insurer—has agreed to cover claims stemming from eating disorders. Some 500 patients will receive $1.2 million when their previously denied claims are reprocessed; the decision settled a class action lawsuit brought by parents of children with anorexia.
In a statement, Horizon spokesman Tom Rubino said the company “believes the settlement is in the best interest of all the parties involved and in line with the direction of federal parity for mental health.”
Horizon said some of its policies provide coverage for eating disorders such as anorexia and bulimia but that treatment benefits were limited because they were classified as nonbiological in nature.
“New Jersey law does not identify anorexia and bulimia as biologically based mental illnesses requiring parity benefits,” the statement noted.
Under the terms of the agreement, Horizon will not admit any liability but will provide “parity treatment to eating disorder claims in the future for all current members who are fully insured,” the statement added.
At issue in particular is a debate familiar in discussions about autism: Is–can– anorexia to be defined as a biologically-based disorder? As noted in a previous post on insurance coverage for autism and also anorexia, a 2006 story in Newsweek reported that it’s precisely how anorexia is defined and understood—-as a biological rather than a psychological disorder that has been a crucial issue in getting insurance coverage for treatment. Insurance companies would prefer to define anorexia as caused by “environmental” factors (due to issues in the family, for instance). In the past years, as in the case of autism, there’s been more pointing to genetic causes for anorexia; for a medical and neurological basis for the condition.
Hasn’t the argument always been that ASD is an “educational” diagnosis (like a learning disability?).
It’s all BS though. Disease is disease- regardless of if it is brain based or not. Today I spent half an hour getting kicked and hit while my just turned 4 ASD brother melted down over cardboard letters. At one point he was standing on the kitchen table with scissors, screaming for me to cut out another letter T. I ended up sitting on the kitchen floor with him, trying to respect his personal space while making sure he wasn’t going to hurt himself or his younger brother. If that’s not an issue worthy of insurance coverage I don’t know what is.
He has yet to receive any services beyond his diagnostic evaluation, medical or educational, because it’s not a diagnosis covered by his insurance policy and he was not considered to have any deficit areas at his preschool screening (he has his case study, which they did not want to provide, next week). Personally I think they’re all nuts to think a kid can have a PDD-NOS diagnosis and not qualify for services.
It’s argued that ABA is an educational treatment. While there are claims that ABA has “recovered” children from autism, this is inaccurate—it can teach children, but curing them from autism is another matter.
I’ve known children who had the PDD-NOS diagnosis and also did not get any or many services, and needed them—if he had an autism diagnosis would it be different?
Yes- I know there is no cure. I’m more interested in services that can make his life easier, and after his meltdown today I’m really just at my wits end with how to help him (normally he isn’t that bad- thank goodness). At this point I could use the 3 hour break that having him in pre-k would bring, if only to scrub crayola off of the walls!
His hyperlexia is what is getting in the way of educational services more than anything else I think. As far as they were concerned at his screening he knows everything he needs for kindergarten. Never mind that he can’t manage going to the bathroom or respond to his name on a consistent basis. Apparently those skills aren’t needed for kindergarten?
If he had presented as nonverbal at the screening I’m sure he would be receiving services right now. I know other children who have received services solely because they live in a bilingual household. It was that he presented as a “quirky” kid who can read and count to 50 that he wasn’t flagged for preschool services and directly referred for the case study.
Naydi,
A word of encouragement. New studies have shown that up to 25% of children withan ASD diagnosis, lose their diagnosis and have a chance at a normal outcome:
http://www.ncbi.nlm.nih.gov/pubmed/19009353?
Your brother seems to have all the attributes asociated with recovery, a diagnosis of PDD/NOS and high intelligence. My own daughter was diangosed with PDD/NOS, was highly intelligent an lost her diagnosis by the 4th grade and has had a normal outcome graduating with a (Magna Cum Laude) dgree, lives on her own, has a good job and a boyfriend and a large circle of friends.
She also had an older sister who loved her very much as a toddler and accepted her as she was. Your younger brother seems to have the gift of an understanding older sibling.
Good luck to you.
Naydi- I don’t have anything helpful to add about services as I live in a different country, but I just wanted to let you know that you’re not alone. My kids are older now, but I remember living for the hours that they were in school so that I could just repair the house damage- forget about time to myself, just try to fix everything so that it could get broken again. It can be extremely frustrating and exhausting at times.
I always tried to keep in mind that it was considerably more frustrating for my kids as at least I could communicate to other people exactly how horrible I was feeling, ask for what I wanted, etc., but keeping that in mind isn’t always easy to do when you’re in the midst of yet another meltdown. I hope that things get better for all of you soon, and if you ever need someone to vent to please don’t hesitate to contact me.