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Family rejects insurer's claim

After years of paying for a badly disabled boy's nursing care, Blue Cross felt he no longer needed it. His parents sued.

December 30, 2007|Lisa Girion | Times Staff Writer

At 13, David Denney's body functions like that of a baby. Severe brain damage halted his motor development at 4 months.

Unable to walk, sit up, speak or even eat by mouth, David is cared for by a licensed vocational nurse who feeds him formula through a stomach tube, watching closely in case he retches.

Blue Cross of California, the family's health plan, paid for the nurse for most of David's life at a cost of about $1,200 a week. Then about two years ago, the company decided that David didn't need a nurse anymore -- contradicting the opinions of two of David's physicians -- and it stopped paying.

"He's fragile, very fragile," said the boy's mother, Amparo Denney of Torrance. "It's not humanly possible to do this without help."

As a matter of course, insurers scrutinize what physicians order -- watching for unnecessary drugs, questionable treatments, experimental and unproven therapies, unwarranted surgery.

The extent of treatment denials by insurers is unknown. But patients are contesting them more than ever.

A small fraction of the 18 million Californians in health plans dispute denials. But the number of such disputes involving the state's five biggest plans, including Blue Cross, nearly doubled since 2001 to 1,014 last year, according to statistics compiled by the state Department of Managed Health Care.

Although there is wide variation among the state's biggest health plans, overall about a third of the 4,259 patients who sought reviews over the six-year period succeeded in overturning denials, according to a Times analysis of the data.

Many people who are denied treatment never contest it because they are unaware that they can or are too caught up in their medical crises to bother. As a result, some denials go unnoticed; some draw headlines.

A much-publicized pair of decisions this month by insurer Cigna HealthCare to deny and then permit a liver transplant for a 17-year-old girl from Northridge drew much criticism after she died hours later.

Gerald Denney said he was so frustrated by his inability to persuade Blue Cross to restore his son's nursing coverage that he decided to hire a lawyer rather than contest it through a regulator's independent medical review process.

The family sued Blue Cross this year, seeking to reverse its action. The insurer opted to go to arbitration rather than to court, as was allowed under the Denneys' policy.

Shannon Troughton, a spokeswoman for WellPoint Inc., the insurer's Indianapolis-based parent company, declined to discuss the case while it is in arbitration.

But Troughton said the overall increase in treatment denial disputes reflected a greater recognition within the insurance industry of the importance of independent medical reviews. She said it also showed diligence by Blue Cross in informing members of their review and appeal rights.

In addition, Troughton said, Blue Cross has a team that routinely examines developments in medical science, such as new drugs and surgical procedures, to determine what care is state-of-the-art and should be provided to members. The Medical Policy and Technology Assessment Committee is made up of physicians who work for Blue Cross, as well as doctors who treat patients, and it takes input from experts, she said.

"We review our medical policies annually to help ensure the most up-to-date scientific evidence is reflected in our policy positions," Troughton said. "We continue to monitor and review treatments available to members and update policies as appropriate."

For insurers, the scrutiny is part of the process that keeps a lid on costs and helps safeguard against ineffective, inappropriate and even unsafe treatment.

But for some patients, denials can come as a shock and create great hardship, often at an already tough time.

Many people end up paying for rejected treatments themselves, often going into debt. Some go without the treatment. Others qualify for public programs, and the costs are shifted onto taxpayers.

That's what happened with David Denney.

Desperate for help and fearful that David's condition would rapidly deteriorate without the watchful eye and skilled care of a nurse, the family turned to Medi-Cal. The state of California's program for the poor and disabled stepped in and has paid for 40 hours of nursing care a week ever since.

Because Gerald Denney is a self-employed mortgage broker, the family buys its own health coverage, paying a $2,907 quarterly premium for four, including David's older sister.

The Denneys have continued to pay their premiums, and Blue Cross has continued to cover the family, as well as most aspects of David's medical care, such as physician visits, prescription medications and hospitalizations.

The family said they were happy with the service and coverage Blue Cross provided -- including an expensive wheelchair specially adapted for David -- until they were denied the nursing care they believe is necessary to their son's well-being.

"That's why we got insurance," Gerald Denney said.

A rare disorder

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