Coverage for augmentative communication devices.

Q In order for my daughter to participate in school, she needs an augmentative communication device. I can't afford to purchase one myself, and my insurance company says they will not cover the cost because it is not a "medical necessity." How can I get coverage for this device? Do I need a letter from a doctor saying it's medically necessary?

A There are some wonderful communication devices available for children these days. They can enable a child with a severe communication disability to communicate effectively, thus creating a foundation for education, social activities and future employment. The problem, as you already know, is that some of the devices may be expensive, and insurance companies don't always cover the costs.

The first issue in dealing with an insurance company on a problem such as this is to determine whether there is a specific policy provision that excludes reimbursement for communication equipment or "durable medical equipment." If there is no such policy provision, there's a great deal you can do to ensure that the device is paid for by your insurance company.

It's important to remember that insurance policy rules are usually very specific and extremely precise. If a product is described inaccurately, or a claim does not include all of the necessary paperwork--or "documentation"--the insurance company may not pay for it, even if the item is covered by the policy. And, in some cases, an insurance company may phrase the reason for the rejection of the claim in technical or bureaucratic terms that are difficult for a consumer to understand.

Communicating with consumers

Most insurance companies, I think, try very hard to communicate effectively with consumers. However, companies are very careful about how they phrase things these days because of potential legal implications. In addition, insurance companies generally process claims by computer, and there are only a certain number of coded sentences that can reasonably be placed on a computer.

Thus, the reason for the claim rejection printed on the EOBS ("Explanation of Benefits Statement") is likely to be in very general technical language. If an insurance company wants a letter from a medical doctor before it will pay a claim, for example, the EOBS may contain a statement such as "Documentation Incomplete" or "Not Medically Necessary."

A phrase such as "Not Medically Necessary" may simply mean that the insurance company cannot further process the claim until the documentation is complete. In the meantime, the claim will be coded as "Not Medically Necessary" in the computer, since the company can't verify that the equipment is medically necessary without complete documentation.

Your next step should be to find out the specific reason for the rejection of your claim. Insurance company representatives are usually quite willing to help consumers understand the claims process. If the insurance company representative who answers the phone isn't able to help, ask to speak with a supervisor. Most supervisors have been with a company for a long time, and are usually quite knowledgeable about the details of the claims process.

Prentke Romich Company, a manufacturer of communication devices, publishes How To Obtain Funding For Augmentative Communication Devices, an excellent booklet on filing insurance claims. The booklet, which costs $5, includes definitions of basic terms and sample letters from doctors and therapists. For a copy of this booklet, contact Prentke Romich Company, 1022 Heyl Road, Wooster, OH 44691, 800-262-1984.

Alternate sources of funding

If your insurance policy does specifically exclude communication devices or "durable medical equipment," there's really not much you can do to persuade the company to pay for the device. However, alternate sources of funding may be available.

Since communication is essential for education, for example, the local public school district may be willing to purchase a communication device for a child with a disability as long as the need for the device is noted in the child's IEP ("Individualized Educational Plan"). State agencies or charitable organizations may also be willing to purchase such a device.

I think the most important thing is not to give up until you've thoroughly explored all of the possibilities. A child's right to communicate effectively, in spite of a disability, should not to be denied for financial reasons.

In this column, Richard Epstein answers readers' questions about health insurance. Send your questions to him at Exceptional Parent, 209 Harvard St., Suite 303, Brookline, MA 02146, or fax questions to [phone].

If your question relates to a specific health insurance claim, please include copies of any materials you've received from the insurance company. (Please, don't send original!) Include your address and phone number. To insure privacy, only your initials and state will be used in the column. Due to time constraints, it is not possible to respond to letters individually.

Technology Resources

* The Electronic Industries Association (EIA), a 70-year-old trade organization representing all facets of electronic manufacturing, offers Extend Their Reach, a 24-page pamphlet about assistive technology. Written as a general introduction to assistive technology, the pamphlet includes information on computers; environmental controls; telephone and communication services and funding sources to help people pay for assistive devices.

Single copies of the pamphlet are free; each additional copy is 90 cents. Extend Their Reach, EIA, 2001 Pennsylvania Ave., NW, Washington, DC 20006-1813, [phone]. * Unlocking Tommorow is a 56-minute documentary video on assistive technology. The video shows individuals with disabilities using a full range of assistive technology--from very simple to sophisticated adaptations--in recreation, education and employment.

The video, produced by Georgia Public Television (GPTV) with support from the Texas Planning Council for Developmental Disabilities, has closed captions and DVS (audio description for people with visual impairments).

Texas residents can obtain the video at no cost by calling [phone] (toll-free in TX only). For all others, the video costs $30; contact GPTV Tape Sales, 1540 Stewart Ave., SW, Atlanta, GA 30310, [phone].

* Teens with hearing impairments and their hearing friends socialize on the PC Pals Teen Network, a computer bulletin board on American Online (AOL), a commercial online service. PC Pals, a joint venture of the Alexander Graham Bell Association for the Deaf and Oticon, offers a special interest place for teens from across the country to discuss topics ranging from summer jobs to movies and books. There's also a chat group where up to 40 teens can "talk" to each other at the same time. Currently, the chat group meets on Sundays at 7 p.m., EST.

To use PC Pals, you will need a computer, modem, telephone line and subscription to AOL. To order an AOL starter kit and free software, call [phone], ext. 6751. There is a monthly charge of $9.95 for five hours of connect time per month; additional usage is $3.95 per hour. AOL can also be accessed through some schools and libraries.

To find the PC Pals board, sign on to AOL and enter the keyword "deaf" to go to the deafness and hard of hearing area. Then, scroll down to and select "PC Pals Network."

For more information, contact the Alexander Graham Bell Association, 3417 Volta Pl., NW, Washington, DC 20007, [phone] (Voice/TTY).