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Insurance coverage for incontinence products.

Q My child has a disability and is incontinent. He will never be potty-trained. Is there any way to get our insurance company to cover the cost of his diapers?

A This is a problem for many parents of children with disabilities. Diapers are expensive, particularly when required on a long-term basis. And if they are being used as part of a doctor-recommended treatment Program, logic suggests that unless they are specifically excluded by your insurance policy, they probably should be covered.

A number of issues may be related to your insurance company's decision on coverage, however. Flat, there is no clear set of national standards regarding items that insurance policies should cover. One of the goals of President Clinton's health care reform ProPosal is to establish such standards. Hopefully, this Will occur in the not-too-distant future. In the meantime, an insurance company may exclude coverage for specific items as long as it does not violate contractual obligations its agreement with the Policy-holder) or state or federal regulations.

Second, insurance companies seem particularly reluctant to pay for items that are not considered a part of traditional medical care, or that may be used in a non-medical situation. One can certainly understand an insurance company's concern about establishing a precedent by covering such items. However, companies may pay for these items if it can be shown that they are part of a treatment plan for a specific medical condition that the policy covers.

Generally, insurance companies do not pay for items unless they are included on the company's list of "medically necessary expenses" and have been assigned a specific procedure code. Therefore, you must first determine whether your insurance company includes diapers on its list of "medically necessary expenses" in regard to disabilities. If diapers are not on the list, the solution needs to begin at that point.

Since this issue affects large numbers of parents, and since groups are often more effective than individual consumers, it may be useful to enlist the help of a local parent support group and a local medical organization that includes doctors specializing in the treatment of children with disabilities (your child's doctor may be able to give you the names of such organizations).

The parent support group can ask the medical association to write a letter to the insurance company confirming that the use of diapers is part of a medical treatment plan in the case of specific disabilities. In addition, the medical association may consider working with the insurance company to develop appropriate rules and procedure codes for such situations.

If diapers are already on the list of "medically necessary expenses," however, Your problem is to determine why the insurance company won't pay the claims you have sent in. The problem may involve technicalities. For example, the company may pay for disposable diapers only, rather than cloth diapers, or it may require a doctor's letter explaining how the diapers are related to the treatment of a specific medical condition. A call to a supervisor at the insurance company should provide this kind of information.

Let me know what happens. Your experiences in dealing with this issue may be very helpful to other parents.
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Author:Epstein, Richard
Publication:The Exceptional Parent
Date:Aug 1, 1994
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