Boy fights illness, HMO Struggle: Just as Bryan DeWitt began to recover from a stroke, he and his family learned they had to battle their insurance company for more coverage.

February 05, 1996|By Donna R. Engle | Donna R. Engle,SUN STAFF

After 13-year-old Bryan DeWitt collapsed on a school athletic field May 4, his parents found themselves fighting a battle on two fronts -- helping him recover and getting their HMO to pay for the physical therapy he needs.

The Westminster teen-ager, son of Karen and Gilbert A. DeWitt Jr., had suffered a stroke, a medical condition so rare in adolescents that physicians weren't sure at first what was wrong. He was taken to Carroll County General Hospital, then transferred to Johns Hopkins Hospital's Children's Center, where a magnetic resonance imaging scan confirmed the diagnosis.

The stroke left Bryan paralyzed on his left side. He is left-handed, but had to learn how to write and eat and throw a basketball with his right hand. He learned to use a wheelchair, then to walk with a cane and brace, then to walk unaided.

The second part of the battle began after Bryan returned home in June and started physical therapy. That's when the family learned that its health maintenance organization covers only 60 consecutive days of physical therapy each year.

The wording is important. Mr. DeWitt learned the hard way that 60 consecutive days meant just that, including Saturdays and Sundays when the physical therapist's office was closed.

"We thought they wouldn't count weekends," said Mrs. DeWitt. The family's health insurance is provided by The Prudential under a contract with Carroll Christian Academy, where Mrs. DeWitt teaches and their three children are students.

Bryan is expected to continue to need physical therapy for about a year.

Dr. Rebecca N. Ichord, a pediatric neurologist who treated him at Hopkins Children's Center, said: "If he doesn't receive physical therapy, the joints on the affected hand are likely to become stiffer and he would be able to have less use of that hand, and the same thing with the leg."

The DeWitts couldn't afford physical therapy at $90 a session, five days a week. So they tried to do it themselves. Bryan used the weight room at his school and worked out with his mother and father. Once a month, a therapist who is a fellow parishioner at Church of the Open Door in Westminster worked with him for free.

It was difficult because Mr. and Mrs. DeWitt weren't always sure they had the exercises exactly right. "We're not trained," Mrs. DeWitt said.

Mr. DeWitt continued filing appeals with The Prudential. Each appeal was denied on the grounds that additional therapy isn't covered in the contract, he said.

Prudential spokesman Anthony Davis said he couldn't discuss any individual case. He said the insurer has an appeal process, but refused to explain how it works. "That's not something I want to give out. It's proprietary, I would imagine," he said.

The Prudential HMO meets the minimum requirement for outpatient rehabilitation services established by Maryland law -- 60 consecutive days per condition per year.

Prudential's HMO has a full three-year accreditation from the National Committee for Quality Assurance, the highest level of accreditation given by the committee. The NCQA, formed by HMOs, rates managed care plans on criteria that include whether the plans use reasonable processes to decide what health services are appropriate.

Mr. DeWitt argues that the HMO should extend physical therapy coverage for an unusual case such as Bryan's. "How often do you get a kid with a stroke?" he said.

Not very often. The National Stroke Association doesn't keep data by age, but spokeswoman Rachelle Trujillo estimated that of the average 550,000 victims of stroke a year, no more than 400 are between the ages of 1 and 14.

The family's friends and fellow church members have helped. At Christmas, the DeWitts received $12,000 and a letter from Carroll County Physical Therapy reducing the charge for Bryan to $30 a session.

Bryan now is receiving the 60 days of physical therapy covered by Prudential for 1996, although he lost several days because of the Blizzard of '96.

In the meantime, Mr. DeWitt said he will continue to appeal for insurance coverage while the family uses part of the Christmas gift to pay a specialist in learning disabilities to work with Bryan one hour each day.

"Even from a monetary standpoint, it makes more sense to make this young man viable in society than to make him dependent on society," Mr. DeWitt said.

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