Danny Stein was recently voted "Most Valuable Player" of his ice hockey team in Bethpage, New York, and like most eight-year-olds, he hasn't finished growing or playing hard. But two years ago his parents' insurance carrier didn't seem to understand, refusing to cover new lower limb prostheses for Danny and classifying them as "durable medical equipment" that could be manipulated somehow to fit the youth for three years.
Patty Stein, Danny's mother, had made a practice of keeping files on Danny's medical expenses so that filing with her husband Thomas's insurance company, associated with the National Association of Letter Carriers (NALC), would be simple when the time came. Two years ago she filed as usual, and the Steins waited for the usual approval. Surprisingly, coverage was denied. Patty was told by an insurance company representative to simply refile the claim and submit more medical evidence.
"They led me to believe that this is common," she said, and she did as the company advised. As they waited for the NALC to review the resubmitted claim, an "open season" period during which the Steins could have changed insurance companies passed by. Conveniently for the NALC, the Steins didn't receive their second and final denial until after this term ended, and they were stuck with the disappointing carrier.
What barred Danny from new legs was a 1997 revision in the NALC's Health Benefit Plan that classified Danny's legs as "durable medical equipment," a policy change Patty and Thomas Stein had no idea had been made. The carrier awarded Danny's parents a mere 15 minutes with a health representative from their area, armed with the amended benefit guide, and a recommendation to appeal to the U.S. Office of Personnel Management (OPM) within 90 days if they weren't happy with the NALC's denial.
"It was absurd," Patty said, prepared to fight. "Somebody had to listen." After enduring the red-tape runaround in Washington's OPM and filing the appeal, Patty got the same results. The federal agency, capable of overriding and setting provisions on every federal insurance company in the nation, upheld the NALC's denial for reimbursement and left the Steins with little hope for a reversal. Medical consultants to the OPM said the prostheses could be manipulated to last three years, and advised Danny's parents to file suit in federal court.
"The insurance companies make you feel responsible for the prices of artificial limbs," Patty said. "To take the coverage all away was like getting the birth defect slapped in your face." But Danny hadn't slowed down his routine of inline hockey with the 10-and-under division "Devils" in his hometown or his rock climbing, skiing or running, so the battle continued.
ACA helps to win the reimbursement game
Through the ACA, Patty Stein was placed in contact with James Kaufman, an ACA board member. Kaufman agreed to intervene on Danny's behalf, and began a daily crusade, recommending to Sen. D'Amato and his legal council that the OPM reverse its decision. D'Amato took Kaufman's advice and wrote a letter to the OPM. Within three weeks the OPM responded to his letter, stating that the case had been reviewed and that they were reversing their original position. As a result of the Stein's fight, Kaufman's intervention and D'Amato's willingness to listen and act, the NALC now provides reimbursement for prostheses and no longer categorizes them as "durable medical equipment," a ruling that has set a nationwide legal precendent for the NALC's benefits guide.
But Patty Stein wonders about the people fighting insurance companies from hospital beds who need prostheses to give them back their lives. She's concerned about other parents and children who will face the same obstacles her family faced.
"Parents can't just sit by and let it happen," she said. "We've got to put our voices together and fight. You have to keep going." Patty Stein played the reimbursement game until the rules were changed, but who can tell when the rules will change again.
One battle certainly does not win the war; however, the ACA will continue to tackle hard-nosed insurance carriers on behalf of people with limb loss for better prosthetic coverage until the war is won.
Thanks to his new bilateral prostheses, Danny Stein won a second place trophy for roller hockey this spring.
