Insurance abruptly stops covering Spokane man's long-term care

SPOKANE, Wash. A motorcycle wreck left a Spokane wife dealing with more than her husband s critical injuries. It has also left her with a complex insurance problem more than two-and-a-half years after the wreck.

Paula Barr recently contacted 2 On Your Side to help navigate and solve her growing insurance dilemma. Barr said her insurance company abruptly stopped covering care for her husband s long-term care facility, leaving her with no good options to care for her husband.

It all began November 26, 2012.

I was walking to the other room, and I just had a vision, Barr said. I don't know what else you'd call it, of his motorcycle laying on its side, and it was pitch black.

She said that is when police called. They said her husband, Doug, had been riding his motorcycle when he was hit by a pickup truck at Sprague and Browne. Doug had been pinned under the wreckage for at least ten minutes, causing serious brain damage from lack of oxygen.

They told us they didn't think he was going to make it, she added. He was so bad.

The 22-year-old at the wheel of the truck was cited for failure to yield. Authorities determined the crash was just a terrible accident.

He literally left a tire track right across his abdomen and crushed both of his kidneys, Barr went on to add.

Doug now requires kidney dialysis three times a week just to stay alive.

For 18 months, he's been juggled from hospitals, to brain trauma centers, to long-term care facilities. Barr said sometimes Doug understands what happened.

He doesn't know where he's at, Barr said. He thinks sometimes he's 17. Sometimes he thinks he has other wives. So, he's all mixed up.

Doug s treatments were standard until a few months ago. That is when Barr was told that Doug s insurance coverage at Alderwood Nursing Home was ending.

The nursing home called me at 6:30 in the morning on the 11th, saying I had until the 15th to get him moved, claimed Barr.

Premera Blue Cross told her Doug's condition wasn't showing significant progress. She had been preparing to move him in July, because insurance also only covers six months in such a highly-skilled nursing facility. For the other six months of the year, Barr was at a loss.

She told KREM 2 News that she did not know she only had six months of coverage.

You never realize that one day you're going to be stuck and you're not going to have any help, Barr stated. Even though you paid that insurance company for 20 years and never really used it that it comes down to the point where you have nothing.

KREM 2 s Whitney Ward spoke with the director at Alderwood, who could not give specifics, but said she sees this happen regularly. It is based on skill/ability -- once a patient plateaus in their progress, insurance companies can, and often do, stop coverage.

Premera said all of these criteria must be met to qualify for ongoing inpatient treatment.

Ward asked Premera leaders to explain how they justify stopping coverage early if a plan specifics a patient has 180 days of coverage.

According to the plan, what was laid out in that plan, we just administer how the plan was designed, said Premera s Melanie Coon. And so, in that letter, I believe the criteria was laid out. And I believe we heard from the provider that the criteria was not being met.

Ward checked back in with Premera to ask if Doug had any other choices for a different type of treatment facility for the remaining six months of the year. Premera employees had several phone conversations with Barr. However, they had not offered anything concrete.

There are some criteria that need to be met, and the type of care he was getting, and in the environment he was getting it, there was no progress being made, stated Coon. So that means there's another level of care needed. And so we sent that letter to say we're going to end that coverage at that facility. But we're going to work with you to see what is the appropriate place this person needs to be.

Barr said she is hopeful but not convinced.

She said all that is left is putting Doug on Medicaid if she cannot find another solution. Yet, her lawyer told her that once Doug is on Medicaid than she loses all of his social security, retirement, and life insurance.

I won't have anything, stated Barr.

Alderwood made an emergency appeal to Premera, It asked them to, at least, keep covering Doug for the 180 days he is entitled to.

The insurance company told KREM 2 News that is still being decided.

I could put him back in St. Luke's Rehab for another 30 days, but that cost me $10,000 last time. That was my portion.

Barr said it is just one more impossible decision she has been forced to make. Her husband told her that he does not want this and he does not want to be like this.

I said, 'well, there's not much we can do. We're praying and hoping you get better, said Barr.

She said he even asked the people at the dialysis clinic to help him die.

If he'd been brain dead, we would have taken him off the respirator, she added, but because he wasn't, I can't just take him off the dialysis and let him die. I just can't do it. He's still in there.

Now all Barr can do is wait and leave you this:

What do you do when your spouse is hurt? You stay there. You do the best you can. You go without paying the bills. Things don't get fixed. You just live with it and now it's going to get worse. So, I'm kind of at the end of my rope.

Doug worked in the Spokane City Engineer s Office for 20 years. He has the same insurance plan that countless City workers also have now. Of course, it is important to note that all insurance plans have limitations but this might serve as a reminder to review your policies.


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