Insurer Changes Policy on Power Wheelchair
"GMA" tries to get answers after family's desperate appeals go nowhere.
March 4, 2008 — -- An insurance company changed its policies on covering motorized wheelchairs after a review of its guidelines, sparked in part by a 3-year-old boy's story on "Good Morning America."
Initially, Assurant denied Liam Russell's claim for a power wheelchair, much to the surprise of his parents.
Liam, who has a rare degenerative disease called type 2 spinal muscular atrophy, needed a power wheelchair to ensure his independence, his parents said.
"I remember getting a phone call saying, 'Assurant is denying benefits." And I said, 'Completely?" And they said, 'Yes." They don't, they don't cover power chairs, end of story," Liam's mother Lynn Russell said.
Assurant now will cover motorized wheelchairs for all its individual policy holders, not just Liam. The company's decision could have even broader implications because not covering power wheelchairs is an industry-wide issue.
While the news may be good for the insurer's clients, Liam's parents didn't wait for a policy change. The Russells were able to raise money to purchase the special chair, which can cost more than $30,000.
Find out more about Liam's story below.
When Liam Russell was about a year old, his parents noticed a decline in his physical abilities.
"I just expressed some concern that he wasn't pulling up to his knees," said Liam's mom, Lynn Russell. "He didn't seem to be crawling quite as much."
Eventually, Liam was diagnosed with a rare degenerative disease called type 2 spinal muscular atrophy.
"The hardest thing was calling the pediatrician," Lynn said. "I just thought she would say I was imagining things. I didn't know that it was a lifelong illness."
Doctors say Liam will never be able to walk. Already, his arms and legs are so weak he cannot even sit up on his own. "He can't roll by himself, if he is thirsty he can't sit up and get water," Lynn said.
There was one thing that doctors said could help him lead a more independent life -- a power wheelchair. "We decided to try to get him a power wheelchair right away," Lynn said.
Coverage at Insurer's Discretion
But when the Russells submitted a claim to their insurer, Assurant, they were denied coverage of the wheelchair.
"I remember getting a phone call saying that Assurant is denying benefits and I said, 'Completely?' And they said, yes, they don't cover power chairs, end of story," Lynn said.
But according to their policy, they were covered for "durable medical equipment" that the insurer determines to be covered -- vague language leaving Assurant free to cover what they want.
Consumer advocates say health insurance companies often write policies in a way that gives them flexibility to deny claims.
"In black and white in that policy it says we will determine what coverage to provide," said Gail Shearer of Consumer's Union. "That doesn't give a lot of power to the consumer. That's one enormous loophole."
Instead they offered the Russells a manual wheelchair, which Liam couldn't manage to use on his own.
"I think the language in the policy is confusing and meant to be confusing," Lynn said. "The bottom line is that they are a money-making business, and paying out for power chairs probably doesn't look good in their checkbook."
After two appeals, Assurant still wouldn't cover Liam's chair.
So Ben and Lynn, small business owners with a modest income, were left with no choice but to scrape together the money for their son's chair, which cost $23,000.
Appeals Don't Get Far
Liam's furious grandmother, Amy Kaplan, decided to take on his battle for coverage.
"All the conversation is about the uninsured and the underinsured and I am trying to add a third category called the falsely insured," Kaplan said.
Kaplan's tireless efforts with the Oregon Insurance Commission did yield some results.
Assurant, which made $8 billion in gross profit last year, decided to offer the Russells a one-time payment of $2,549 toward the purchase of the $23,000 chair.
The company explained that "this decision is made in accordance with coverage provisions" and based on "13 months" of rental of manual wheelchair, which their policy covers.
"It was never explained why a child who is going to spend his life in the chair needs a rental for 13 months," Kaplan said.
And it was surprising to the Russells, since Assurant had repeatedly told them there were no coverage benefits for a power chair under their policy.
"We were denied again and again without any explanation other than they don't provide it," Russell said.
Kaplan asked about the change when she presented her case before Assurant's grievance panel.
"These actions and your low-end offers display not only bad faith denial of coverage, but arbitrary decision-making," said Kaplan during the April hearing, which was recorded on audio tape.
Despite her efforts, Kaplan was told she and her family had reached the end of the appeals process. Liam's power wheelchair would not be covered.
Grandmother Writes to 'GMA'
In desperation, Liam's grandmother wrote "Good Morning America" a letter asking for help in getting some answers.
"GMA" called Assurant and asked about Liam's case. After five months of no communication, Kaplan got a phone call from the office of Assurant's chief executive requesting a phone meeting. After the call, however, the power wheelchair was still not covered.
"They know it is wrong and no one is holding these corporations to reasonable accountability," Kaplan said.
ABC News' Chris Cuomo spoke to an Assurant senior executive, who refused to speak on camera about Liam's case.
Now, almost two years into the fight, the Russells are still out of pocket $23,000 for a wheelchair their son will outgrow when he turns 10.
"We're up against something that has to be changed," said Liam's father, Ben Russell. "I've heard people say, if it's not broke then don't fix it. I got news for you, folks. It's broken and we need to fix it."
After Cuomo's phone conversation with the senior executive at Assurant, the company issued a paper statement to "GMA" with an answer, saying they are commissioning a study to review the issue.
Assurant said: "While we must apply contract terms consistently to all policyholders, we understand the health care system is not perfect and the outcomes are not always ideal. We listen to the concerns of our customers, and are commissioning an industrywide study on this issue to see if and how all policyholders can benefit."
The family has set up a fund to help care for Liam:
"Liam Russell Supplemental Needs Trust"
c/o Moss Kaplan
2380 Fairfax Street
Denver, CO 80207
GMA Gets Answers Update
Our last story profiled Mary Casey who could not get the cancer drug Tarceva because the insurer called it experimental for her cancer. (Click here to read the story.)
Casey is now receiving the drug for free from a pharmacist who came forward and wanted to make the donation after our story ran. Casey's most recent test results show that her cancer has stabilized.
A group of attorneys also came forward after the story ran and are filing suit in federal court on Casey's behalf -- pro bono.