Oct 1, 2009 9:12 pm US/Central
Woman Says Aetna Denied Her Inpatient Rehab
CHICAGO (CBS) ―
You think you have good health insurance coverage. Then you or a loved one suffers from a catastrophic, life-altering accident or ailment.
That's what happened to one woman who thought she was fully covered. As 2 Investigator Pam Zekman reports, she fell through the cracks of her insurance policy.
A healthy 62-year-old, Carol Jones was suddenly stricken in May with Guillain-Barre Syndrome, a disease that strikes the nerves.
"I was completely paralyzed except for my arms and my hands," she said.
After three months at Northshore's Evanston Hospital, Carol was transferred to a nursing home for physical and occupational therapy. Barbara Knox, her sister, says "Everyone told us, 'Don't worry. Don't worry. She has coverage.'"
Carol's Aetna policy included coverage for up to 120 days in a skilled nursing facility, which reassured her.
"I hoped that would be enough days to get me where I could be functional," she said.
But after just a few weeks, her daughter, Deborah Dean, says Aetna warned them her mother was not making enough improvement. Dean says she was told her mother would be sent home if she didn't make enough improvement.
"The nursing home doctor was furious," she said.
Manor Care, the nursing home, supplied Aetna with notes showing Jones was making good progress. It warned the insurer that it wasn't safe for her to return home because she lived alone.
Her hospital rehab doctor, Miledones Eliades, said he contacted Aetna to share his concerns. But he said, as in other cases, Aetna's medical reviewer had no rehab expertise.
"Management of her care was taken away from her physicians and given to the insurance company," Eliades said. "They make the rules, and in the end part of their influence is to make a profit."
Aetna reported a net income of more than $1.3 billion last year.
Former insurance industry executive Wendell Potter used to help insurance companies battle health care reform. Now he's urging Congress to pass it.
"The status quo for most Americans is that health insurance bureaucrats stand between them and their doctors right now," he said.
They apparently have in the case of Carol Jones.
Carol has gone from 12 hours a week of nursing home therapy a week to just over two hours a week. Aetna now pays for it at her home.
An Aetna spokesman says it covered her entire four-month hospital and nursing home stay. The company admits its doctor never called back the nursing home doctor about the need for Carol's continued therapy.
Finally, Aetna says since it only managed Carol's insurance plan, the company did not save money by the decisions it made about her care.
Aetna says patients can appeal a decision. But if Jones stayed in the nursing home and lost the appeal, she would have to pay for the treatment.
(© MMIX, CBS Broadcasting Inc. All Rights Reserved.)
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