Therapy patient battles over bills Woman is granted state hearing after two-year fight.

October 01, 1991|By Ross Hetrick | Ross Hetrick,Evening Sun Staff

For more more than two years from late 1987 through 1989, Bonnie Schlenker underwent grueling physical therapy for her chronic back problems. But now the homemaker can move as freely as any other person.

"I now can walk . . . I am what I am today because I went through physical therapy," Schlenker says triumphantly.

But for the last two years she has been fighting another grueling battle. This time it is with a New York insurance company that refuses to pay about $3,500 for five months of physical therapy, contending that it was not "medically necessary."

In her battle, Schlenker is colliding with the growing use of "utilization reviews" by medical insurers. In an attempt to hold down costs, health insurers have increasingly reviewed the medical necessity of various procedures and therapies. Normally this review is done before the service is rendered. But in some cases, such as Schlenker's, benefits are denied after services are given, leaving the patient with the bill.

The Mutual Life Insurance Co. of New York, known as MONY, has refused to pay for most of Schlenker's physical therapy from April through August 1989, contending that it was not medically necessary. However, the insurance company had been paying for the same treatments for the seven months before that period.

What is particularly frustrating to Schlenker is that the insurance company began asking for information about her treatment in May 1989, but refused to say that her benefits were in jeopardy until Sept. 22 that year -- after she had taken the treatment.

Schlenker, a former teacher in the Baltimore County school system, has suffered from lower back problems for 20 years. The problem had worsened and in mid-1987 she was numb from the waist down and needed help walking. In October 1987 she started physical therapy at the Maryland Center for Physical Therapy in Owings Mills on the recommendations of her physicians. The therapy sessions were two to three times a week and included progressively more difficult exercises in a heated pool along with the use of various equipment to treat the problem.

For a year, the treatment was paid for by the Prudential Insurance Co., the insurer that provided health coverage at her husband's workplace. Then in October 1988, Schlenker's husband changed jobs and the new insurer, MONY, picked up payments for the physical therapy.

Then in May 1989, MONY representatives began asking for notes from Schlenker's physicians about her treatment. Worried that this might mean her benefits would be cut off, she called the company's service department. The representative said it was a "formality" and said the benefits would continue as long as the doctors said the treatment was necessary, Schlenker recalls.

As her bills went unpaid, Schlenker repeatedly called service representatives, who said the information had been sent on and the claims would be paid soon. Asking how to reach the main office, she was told that was not allowed and she would have to deal with customer service.

Then at the end of September 1989, Schlenker received a three-paragraph letter from MONY saying it had reviewed her case and had decided to pay for only two physical therapy visits for each month in April, May, June and July. In August and thereafter, the company would pay for only one visit each month. This was less than a quarter of Schlenker's total visits.

By Sept. 1, 1989, Schlenker's husband had changed jobs again and she was now covered by Blue Cross and Blue Shield of Iowa, which paid for her treatment until it ended in December 1989.

Not willing to accept the action by MONY, particularly since no physicians representing MONY had examined her, Schlenker challenged the decision through MONY's appeal process -- with no success.

Schlenker's frustration was increased when she turned to the Maryland Insurance Division in February 1990 and found little help. "I think they have done everything they possibly can not to handle this case," she says. "They've tried to brush me off."

After more than a year of her letters and appeals to various politicians, the Insurance Division on July 22 this year held a meeting between Schlenker and Edward C. Geruldsen, vice president-association operations for MONY. Presiding at the meeting was Nelson Ayling, chief of market conduct life and health for the Insurance Division.

Schlenker had formally asked for a hearing in October 1990. But instead of granting a hearing, the Insurance Division held a meeting, which meant the decision reached by Ayling would carry no force.

At the meeting, Geruldsen said consultants for MONY determined the therapy being received by Schlenker should have lasted only six to eight weeks, not two years, and she should have been using more home therapy. "I get the impression that she gets physical therapy because she likes it," Geruldsen told the meeting. "She insists on it and she is a woman that gets what she wants."

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