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HEALTH : Insurance Firm Told to Pay for Home Care : Coverage: Covina mayor pro tem is suing providers who dispute her sons' need for night nurses.

March 10, 1994|ANDREW LePAGE | SPECIAL TO THE TIMES

An insurance provider was ordered last week to provide in-home nighttime nursing care for 8-year-old Covina twins who risk heart and lung failure whenever they fall asleep.

The preliminary injunction issued by Los Angeles County Superior Court Judge Diane Wayne forces the state's Public Employees Retirement System to pay for 100 four-hour nursing visits while a lawsuit over the twins' care wends its way through court.

If the lawsuit against the retirement system is not resolved before the 100 visits are exhausted, PERS will have to provide full-time hospitalization for the boys, according to the tentative ruling.

In January, the boys' mother, Covina Mayor Pro Tem Linda Sarver, filed suit against PERS, which funds the insurance; Blue Shield, the claims administrator; and Healthmarc, which advises PERS on what kind of care a patient needs. In November, Healthmarc officials told Sarver the nighttime nursing visits were not medically necessary and would not be covered.

The judge's decision, Sarver said, "was like someone telling me my children are probably going to live, rather than that they are probably going to die."

Bradley and Steven Sarver suffer from a rare central nervous system disorder that sometimes causes their hearts and lungs to fail while they sleep. Their nighttime nurses' job had been to anticipate and respond to the boys' apnea, or cessation of breathing, and bradycardia, the slowing of the heart rate. The boys' physician said their chances of serious injury were increased by the lack of night nurses.

But Blue Shield attorney Rick Zimmerman said that the nurses' records he has so far reviewed do not prove the need for that level of care to safeguard the boys.

"There's conflicting information on what these nurses are doing, and how much of it is medically necessary," Zimmerman said.

The Sarvers' previous health insurance company had paid for home nursing nearly all the twins' lives. The twins are insured through their father, a Beverly Hills police lieutenant. The nursing care was stopped after the Beverly Hills Police Department switched health-care providers last year.

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