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Stuttering and Insurance Coverage

The following articles were previously published in the December 1994 issue of the Staff. The Staff was a newsletter published by Aaron's Associates, a support group for children who stutter and their parents. Unfortunately, Aaron's Associates no longer exists. Permission to include these articles in this web site was given by Janice Westbrook, the founder of Aaron's Associates and editor of the Staff.  

Insurance Coverage of Speech Services for Children Who Stutter

The Experts Do Not See Stuttering as an "Educational Issue"

Is Stuttering an Illness?

  


Insurance Coverage of Speech Services for Children Who Stutter

By Janice Westbrook, Ph.D., Fluency Specialist, Staff Editor.

Many insurance companies understand the importance of providing coverage for adequate and early intervention for stuttering. Governmental agencies realize the importance of these services, and children who are insured through Medicaid are eligible for services either through school systems or in clinics. (Many school systems now bill Medicaid for their services.)

Children who are privately insured deserve the same choice of services through their local school system or in a clinical setting. Providers of private insurance should be aware of the following facts:

Many states now have mandated options that insurance companies must at least offer employers the opportunity to accept or decline speech therapy as a part of their insurance plan. In Texas, for example, speech pathology and audiology services have been a "mandated option" since 1983. Laws in this state guarantee that coverage of speech-language and audiology services cannot discriminate on the basis of type of problem, age of onset, or cause of problem

We who are advocates for children who stutter encourage insurance companies to provide coverage for early and adequate intervention for children who stutter. We encourage employers to make such coverage part of their company's plan. We encourage parents to intercede on behalf of their children to make certain they receive the kind of help they deserve.

 


The Experts Do Not See Stuttering as an "Educational Issue"

The following are opinions and observations of fluency experts. Their views reflect the belief that there are neurological explanations for stuttering, even though these await an adequate description. Insurance companies need to be made aware of these more modern and informed opinions.

 

Courtney Stromsta, Ph.D., Elements of Stuttering, Atsmorts Publishing, Oshtemo, Michigan, 1986, pg. 223.

(Stuttering is)...an inconsistent lack of central integrated neural impulse patterns for motoric speech that results in disruption of the motor system giving rise to intraphonemic disruptions marked by abnormal or lack of anticipatory coarticulation. One theoretical basis for coarticulation is preferred neuromuscular patterns produced at a high level of programming. If so, stuttering as a disorder must occur before the coarticulatory input. On the other hand, if coarticulation results from time variation of neural commands for invariant phonemes, then stuttering must originate between these points as an inconsistent defect of coarticulation.

 

Marcel E. Wingate, Ph.D., The Structure of Stuttering: A Psycholinguistic Analysis, Springer-Verlag, New York, 1988, pg. 266.

(Stuttering is)...a special kind of neurologic dysfunction involving, at least as the principal focus, neuronal systems of the left prefrontal cortex and related subcortical structures. At the same time, neural activity on the other side of the central nervous system evidently is part of the problem. There are many parallels between stuttering and aphasia, ordinarily not clearly evident, that become discernible once the parameters of comparison are brought into focus. At the same time there are notable differences between the two disorders, of which the most striking concerns etiology; while it seems clear that both disorders can be induced by cortical damage, there is substantial evidence that much, perhaps most, stuttering is genetic in origin.

 

Ray D. Kent, Ph.D., Facts about stuttering: Neuropsychologic Perspectives, Journal of Speech and Hearing Disorders, 48, No. 3, 1983, pg. 254.

The peculiar weakness that underlies stuttering (and perhaps other disorders such as developmental dysphasia or dyslexia) is a reduced capability to generate fine temporal programs that are necessary for sensorimotor integration, for efficient auditory perception, and for language expression.

 

Nicoline Grinager Ambrose, Ph.D., Ehud Yairi, Ph.D., and Nancy Cox, M.D., Genetic aspects of early childhood stuttering, Journal of Speech and Hearing Research, 36, 1993, pg. 706.

  1. More than two thirds of young beginning stutters report a positive family history of stuttering.
  2. The gender factor in stuttering appears to be related in familial history of stuttering. The male-to-female ratio is higher for subjects with a positive history whereas it is closer to 1:1 for subjects with a negative history.
  3. For relatives of all probands, there were significantly more males than females who stuttered.
  4. In general, male and female probands tended to have equal frequency of stuttering relatives.
  5. Frequency of stuttering was considerably higher among first-degree relatives than among second- and third-degree relatives.
  6. Segregation analyses yield statistical evidence for a major locus component to transmission of susceptibility to stuttering.

 


Is Stuttering an Illness?

From Pediatrics, 71(1): 135-146. January, 1983. American Academy of Pediatrics. By E. Noel Preston, M.D., Peachtree Corners Professional Center, Norcross, Georgia. Submitted [to the Staff] by Carolyn Kolpin, a Fluency Specialist in El Paso, Texas.

The letter from the Medical Care Foundation Peer Review Panel was a plaintive one. "(Insurance Company) has requested we review this claim and give an opinion as to whether stuttering is an illness. If you cannot make a decision on the claim, any suggestions regarding which specialty to send it to would be helpful." The envelope that brought me this letter contained claims forms, rejection notices, appeals, denials of appeals, medical statements, further denials, a flurry of intraoffice memos to and from different levels of the insurance company's hierarchy, and finally a demand from the patient that the matter be submitted to Peer Review for a decision.

The pediatrician characteristically views his patient as a whole, greater than the sum of his parts. He is as concerned with the child's emotional response to hospitalization as he is with the illness requiring that hospitalization. He is as concerned with prevention as he is with treatment, as evidenced by his support of immunization programs, infant car seat legislation, poison control centers, and accident prevention. Naturally a pediatrician would want to treat stuttering: his whole orientation and philosophy demand it.

But to what length does this concern with prevention extend? Stuttering can be handicap, but it's not as handicapping as cancer or quadriplegia. When giving anticipatory guidance, the pediatrician makes many recommendations that are not in any way compensable by third parties. For example, one may recommend that a child go to summer camp, or that a mother stay home from work to be with her children. These recommendations for a "healthy child" are not compensable by third parties. On the other hand, if a child needs rehabilitation as a result of an injury, or due to a handicap such as Down's syndrome, that should be compensable.

It would be easy to write on the consultant's report that stuttering is an illness and the company should pay the claim; but healthcare costs are skyrocketing, and public, third-party payers, and Congress are growing increasingly angry. The insurance company has lots of money and could easily pay the claim, but what happens next year to the premium? If it goes up above the patient's tolerance level, he may drop his coverage, and then if he has a truly catastrophic illness, what will he do? He will use the county ambulance, hospital, and perhaps the county extended-care facility, and all our taxes will increase to help pay for it.

One of the documents from the insurance company stated what it would pay for "medical services essential for necessary care and treatment of sickness," but that "no benefits would be paid for education or training" and that "speech therapy is education or training." Another statement from the carrier said it would pay for speech therapy "if the speech disorder has its origin in a definable illness or injury caused by a diagnosed physiological dysfunction." Several interoffice memos were included stating that "stuttering is not an illness."

I trudged to the dictionary for assistance, and discovered the following definitions:

  1. illness - a condition marked by pronounced deviation from the normal healthy state.
  2. healthy - free from disease or dysfunction.
  3. health - normal condition of body and mind, with all parts functioning normally.
  4. necessary - essential to an end or condition; indispensable.
  5. essential - being that quality underlying all outward manifestations and which is permanent and unchangeable; important in the highest degree; belonging to the very nature or essence of a thing and therefore incapable of removal without destroying the thing itself or its nature or character.
  6. stuttering - a variety of faltering and interrupted speech characterized by difficulty in enunciating.

This being the case, stuttering would be a deviation from the normal healthy state. The stutterer is not free from disease or dysfunction, and he does not enjoy all his parts functioning normally. Therefore, stuttering is an illness.

The pediatrician had referred the patient to a speech therapist (sic), which meant he considered stuttering to be an illness, a treatable condition, and one that would require treatment. In his professional opinion, therapy was necessary.

Another consultant had written, "Stuttering is the behavioral manifestation of a group of speech disorders - some of which are clearly neurological, some apparently psychological, and some not yet defined. In the strictest sense, it is the sign of a disorder, not an illness in and of itself." But what of the disorder that produces the stuttering? Is it not a condition that justifies treatment? Headache may be a manifestation of a group of disorders also, and if headaches can qualify as a diagnosed illness requiring therapy, so should stuttering.

But, does stuttering have its origin in a definable illness or injury caused by a diagnosed physiological dysfunction? Obviously, the carrier is of the opinion it doesn't. There is after all, no cleft lip or palate, dental malocclusion, nasal septum deficit, or other structural abnormality. In this particular case, the pediatrician diagnosed stuttering as a neurologic dysfunction of the speech process, qualifying the stuttering as being due to a "diagnosed physiological dysfunction."

The last question deals with the word "essential." Fluency, or freedom from stuttering, obviously is not essential to life and limb. Many people with more handicapping conditions receive no treatment, but lead productive and satisfying lives. The word "essential" is not used here by the company to describe the patient's state of health or life-style. It is used to describe "medical services essential for necessary care and treatment of sickness." If the pediatrician decided that stuttering was an illness that required treatment, and he recommended speech therapy for the treatment of that illness, then speech therapy in this particular case was essential for the treatment of stuttering.

My recommendation as a consultant was that the company pay the claim.

 


 

If you have questions or need more information you can contact me at:

Overton Speech & Language Center, Inc.
Fort Worth, TX
(817) 294-8408

info@overtonspeech.net

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