Turlock parents battle Blue Shield of California over speech therapy coverage for son’s rare condition

Nov. 27--TURLOCK -- Jennifer and Ron Eivaz claim that a major insurer reneged on a promise to cover speech therapy for their son's rare condition, echoing the concerns of other consumers in California who have struggled to get insurers to approve therapy for speech disorders caused by a medical condition.

As the Turlock parents battled with Blue Shield of California this year, they paid upward of $800 a month for twice-weekly therapy sessions so their son's treatment would not be interrupted and he could enjoy the gift of speech. David Eivaz, 10, has verbal apraxia, which results when the brain fails to send messages to the tongue and facial muscles that generate speech.

David's mother said he has made remarkable progress with intensive one-on-one therapy but that an interruption of treatment would cause him to regress.

Jennifer Eivaz said Blue Shield has belatedly paid reimbursements for a previous benefit year that ran from Nov. 1, 2011, to Oct. 31, 2012, but the insurer has claimed a new policy that went into effect in November 2012 has a stricter limit on speech therapy. She said she believes the insurer made the policy change without the parents' knowledge. "I knew what I had purchased, and then I got information from Blue Shield that the plan had dropped the coverage for speech therapy," Eivaz said.

A Blue Shield spokesman said the company does not change coverage without notifying customers and did not deny service to the Turlock family. "We are well aware of the circumstances and have been trying to work with her for the last few months," Steve Shivinsky said.

Last week, the California Department of Managed Health Care ordered three major insurers ? Blue Shield, Health Net and Anthem Blue Cross ? to stop denying members' access to speech or occupational therapy. The agency said it took action after investigating dozens of consumer complaints.

Health Net also was ordered to pay a $300,000 fine for denying access to therapy for customers. Although she was not among 14 consumers who complained to the state about Blue Shield, Jennifer Eivaz said she understands their frustration.

The parents are ministers at Harvest Christian Center in Turlock. Their initial small-group coverage purchased from Blue Shield provided for a certain number of therapy sessions, plus additional therapy with proof of medical necessity, Eivaz said. She said she spent months asking for the paperwork and haggling with Blue Shield customer-service reps.

She said she got no reimbursements from the company until she posted pointed comments on Blue Shield's Facebook page. "I got a call within a week from customer service, and we received a payout in about February 2013," Eivaz said, noting those payments were for the previous benefit year.

The parents continued this year to pay for their son's sessions with a Turlock therapist who specializes in verbal apraxia, without any clear answers from Blue Shield on whether the therapy was covered, she said. Blue Shield eventually told the parents about a policy change, effective in November 2012, that placed a stricter benefit limit on speech therapy.

Jennifer contends the eight church employees covered by the plan were not notified of the policy change. After the Department of Insurance asked the insurer to respond to her complaints, Blue Shield stated in a letter last month the group had "chosen" a policy that's regulated by the Department of Insurance and allowed no more than 12 speech therapy visits per year.

As for notifications to the parents, Blue Shield's letter said: "The policy was not sent out by Blue Shield. It was the responsibility of the group to distribute information and advise their employees of any changes."

As an associate pastor at the church, Eivaz said, she keeps a close watch on the group's health insurance and would have noticed the change in coverage.

Shivinsky of Blue Shield said Tuesday that type of policy provides for a dozen sessions per year and the clients are responsible for costs of therapy beyond that. "We have not denied service," he said.

The spokesman said Blue Shield would review specifics of the cease-and-desist order before deciding whether to appeal.

Marta Green, a spokeswoman for the Department of Managed Health Care, said the three insurers have until Dec. 3 to contest the orders and then 30 days to request a hearing. The insurers will be faced with reimbursing customers for the cost of speech therapy if the state agency prevails.

Eivaz said David's progress has allowed them to reduce the therapy this fall to once a week, so it's costing around $400 a month. As of this year, David is in a mainstream fifth-grade class at Dennis Earl Elementary School.

"When he was 41/2 years old, he wasn't speaking at all," she said. "We were able to pay for the therapy, but our concern is for other kids whose parents are not able to navigate the process. They just don't get the help."

Eivaz said she and her husband likely will purchase a health plan for next year through the Covered California health exchange and will find out whether it's easier to get the therapy approved.

Bee staff writer Ken Carlson can be reached at [email protected] or (209) 578-2321.

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