What to do if your helmet insurance claim is denied

Some insurance companies have a bad reputation where helmeting and banding treatments for flat head syndrome are concerned. Many parents have reported significant problems with Blue Cross Blue Shield, United Health Care, and TRICARE. It is difficult to generalize because these companies offer so many different types of policies and the coverage may vary quite a bit depending on your geographic location, employer, and policy.

TRICARE, the insurer that covers military problems, was exposed in a 2010 news story for their compliance with cranial deformity care up until helmeting. Babies whose physical therapy and treatment for cranial deformities had been covered began to complain publicly about the insurer’s abrupt to decision to not cover helmets or bands, calling them cosmetic devices. Blue Cross Blue Shield has been the subject of class action lawsuits in Illinois and Florida for refusing to pay for helmeting and banding of children with cranial deformities. In forum discussions regarding plagiocephaly, scaphocephaly and brachycephaly, United Health Care is frequently complained about, as well.

One approach you can also take if your claim is denied and your insurance is provided through your employer is to contact your human resources department and ask if your employer can help to put some pressure on the insurance agency.

Most of us don’t have the time or money to file a class action lawsuit. We need treatment for our children, and the time frame for effective cranial remodeling is limited. One of the first steps you should take if your claim is denied is to file an appeal letter to your insurance company. The following section will show you how to do that.        

Writing appeal letters

“The AMA declares: (1) that treatment of a minor child’s congenital or developmental deformity or disorder due to trauma or malignant disease should be covered by all insurers; (2) that such coverage shall include treatment which, in the opinion of the treating physician, is medically necessary to return the patient to a more normal appearance (even if the procedure does not materially affect the function of the body part being treated); and (3) that such insurability should be portable, i.e., not denied as a pre-existing condition if the patient’s insurance coverage changes before treatment has been either initiated or completed. (Sub. Res. 119, I-97; Reaffirmed, A-03; Reaffirmation A-05; Reaffirmation A-08)”

The above quote from the American Medical Association is frequently used in appeal letters by parents of children with plagiocephaly, scaphocephaly and brachycephaly.  Your appeal letter should include letters from the prescribing doctor which emphasize the medical importance of the helmet or band to your child’s development, evidence proving that the helmet or band is not just for cosmetic purposes, any relevant diagnostic imagery, and a brief background of your child’s case.

Even though it can be excessively difficult, remain calm and professional in the tone of the appeal letter. Do not focus on the pain you feel as a parent – focus on the medical necessity of the helmet or band for your child. In other words, keep it human, but don’t go overboard. The person who reads your appeal will most likely, as cold-hearted as it might sound, skip over the personal story and focus on medicine. It doesn’t hurt to include a little heart, though.