Health plan fails granddad when it was needed most
By Ridgely Ochs
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Published: September 29, 2009
WHEATLEY HEIGHTS, N.Y. — For at least six years, Mervyn Urquhart, 83, paid $200 to $250 a month for a Medicare Advantage plan.
His grandson
John Arline of Wading River, N.Y., said the retired engineer believed the insurance — a privately run plan offered to seniors as an alternative to traditional, government-run
Medicare — would take care of his health needs.
Arline said that has not been the case: He and his sister ended up paying $15,000 for Urquhart’s stay in a nursing home when his health plan denied coverage for physical therapy.
"The entire process is extremely broken,” said Arline, associate emergency management director for four city hospitals.
Others are also unhappy with Medicare Advantage plans, in which 10.2 million seniors are enrolled.
President Barack Obama says the plans cost the government too much and that eliminating them would save $200 billion. Others say the plans confuse seniors and lack sufficient oversight.
Mark Wagar, chief executive of Empire BlueCross BlueShield — which administered Urquhart’s plan — defends them. He said they typically offer more benefits than regular Medicare with lower premiums and out-of-pocket costs.
On Jan. 3, Urquhart, who has had Alzheimer’s disease since 2001, was admitted to
Good Samaritan Hospital Medical Center in
West Islip, N.Y. He had a stomach virus and a deep vein thrombosis, a potentially lethal blood clot, in his right leg.
Until then, Urquhart had been fairly independent.
After the virus and blood clot had been treated, Urquhart’s doctor recommended he be transferred to a rehabilitation facility to help him regain his strength. But on Jan. 12, Empire denied coverage, stating he was not a candidate for physical therapy because of his "cognitive status.”
But Arline wanted his grandfather to receive the care his doctor had prescribed. He appealed twice to Empire and was denied both times. He then appealed twice to Maximus Federal Services, a national board that reviews appeals for patients with Medicare Advantage plans, and was denied. He also appealed twice to IPRO, a not-for-profit health care consulting group. Again, he was turned down.
Worried that a month in the hospital was sapping Urquhart’s strength, Arline and his sister decided to take him to a
Huntington, N.Y., nursing home for a month. They paid the cost out-of-pocket.
"He’s home; he’s walking,” Arline said. "I know that if he didn’t have rehab, he wouldn’t be walking. If he didn’t have restorative care, he might not be here at all.”
Arline said he was infuriated that someone "a hundred miles away” overruled his grandfather’s doctor.
Arline said doctors — not insurance companies — should decide who gets care. And on one thing he is clear: "I am for getting rid of Medicare Advantage plans. If everyone received regular Medicare, they would be ... better off.”
McClatchy-Tribune
Information Services
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