A quadruple amputee, a woman with a spinal cord defect, and a five-year-old who struggles to walk 100 feet. All three were denied insurance coverage on wheelchairs, even though doctors said this equipment was medically necessary. CBS 2's Tim McNicholas reports.
- A quadruple amputee in River North. An Oak Lawn woman with spina bifida. And a five-year-old girl who struggles to walk. All denied insurance coverage for wheelchairs even after their doctors said they need them.
CBS2 is always investigating, dedicated to looking into important issues like health insurance that impact you and your family. Tim McNicholas uncovers just how often the state's largest health insurer is refusing to pay out.
MARTINA ROON: My name is Martina.
TIM MCNICHOLAS: Whatever life throws at Martina Roon, she keeps pushing forward.
- Push, OK.
TIM MCNICHOLAS: Just ask her mom, Patricia.
PATRICIA ROON: Martina goes daily with pain management struggles and mobility issues. But other than that, she's a amazing little girl.
TIM MCNICHOLAS: Sometimes your pain is really big or is really little?
MARTINA ROON: Really big.
TIM MCNICHOLAS: And the wheelchair helps you?
MARTINA ROON: Yeah.
TIM MCNICHOLAS: Medical records from the Shirley Ryan AbilityLab say Martina has a "complex vascular malformation," a "leg length discrepancy," "chronic pain," and a "history of cellulitis." It's led to hospitalizations and a 2019 surgery. Some days are better than others, but when it's bad--
MARTINA ROON: Hurts really bad.
- She does have a significant decline in function and inability to keep up with her peers or be out independent in the community safely.
TIM MCNICHOLAS: The day we met Martina, she decided to walk home with mom's help. She didn't make it out of the park before she fell. She tried to get back into this wheelchair, which was loaned to her by a local charity. Her mom says she fell partly because of her fatigue and partly because this chair is too big.
PATRICIA ROON: She falls down and gets hurt frequently due to her abnormal gait.
TIM MCNICHOLAS: Patricia says Martina needs her own chair-- one that fits-- and her doctors agree. They determined it's medically necessary, which they clearly explained to the Roon family's insurance provider in November 2019 and again in April 2020.
PATRICIA ROON: We pay these insurance premiums. They're supposed to help us. They're supposed to get us what we need.
TIM MCNICHOLAS: But both times, Blue Cross Blue Shield of Illinois denied Martina a wheelchair. Their logic-- the member is able to walk. So a wheelchair isn't necessary.
PATRICIA ROON: I was kind of dumbfounded. Yeah, she can walk. But do you know what. She can't walk long distances. Her quality of life is less. She can't play with her friends. She can't run around. And, you know, I'm strong, but I'm not that strong to be able to carry a five-year-old around.
TIM MCNICHOLAS: The Roons first reached out to us after seeing our story on Abla Gharib, a quadruple amputee.
ABLA GHARIB: This is a human right to live in the community and live independent.
TIM MCNICHOLAS: Gharib fought with Blue Cross Blue Shield of Illinois over a power wheelchair-- denied twice all while she used a loaner with a broken arm-rested backrest. A Blue Cross Blue Shield of Illinois employee who never met her wrote, The patient is able to walk a little with prosthetics. And they might still be able to move a wheelchair with their arms. You heard that right. They suggested this woman should walk or push a manual wheelchair.
ABLA GHARIB: It's unfortunately, some of the insurance company put profit ahead of health.
- A viewer reached out to the Morning Insiders with the police--
TIM MCNICHOLAS: Suddenly, days after a CBS2 report on Gharib last August, Blue Cross Shield of Illinois agreed to pay for a power chair.
Do you think it should get to that point where you have to call a journalist?
ABLA GHARIB: Absolutely not. I had to go through all the struggle. It was very frustrating, and I was crying. And I'm very depressed.
BOB SHEA: Everything you're looking at is donated.
TIM MCNICHOLAS: Bob Shea says he hears similar stories every week. He runs a nonprofit called Devices 4 the Disabled that gives medical equipment to people in need often because their insurance won't cover it. Without coverage, some power wheelchairs can cost tens of thousands of dollars.
BOB SHEA: Unfortunately for the bad actors in the industries, they have a real profit incentive to deny claims.
TIM MCNICHOLAS: Shea and his nonprofit have developed a reputation even among insurers,
BOB SHEA: We get calls from insurance companies who deny their client the equipment but then call us to provide the equipment to their client.
TIM MCNICHOLAS: How do you respond to that?
BOB SHEA: No. They're paying you to cover for that.
TIM MCNICHOLAS: We wanted to know how many people complained to the state about denials on medical necessities. We found the company with the most complaints is also the state's largest insurer-- Blue Cross Blue Shield of Illinois headquartered at their iconic Randolph Street tower.
Since 2015, 436 complaints. Five times more than any other insurer with 66 of them marked by the state as confirmed violations. Also, the highest total in Illinois. Since Blue Cross is by far the biggest insurer, it stands to reason they have the most.
We also found dozens of complaints about other companies. But advocates like Shea argue there's not enough oversight for any of them. And the Illinois Department of Insurance tells us they have limited jurisdiction over claim denials for medical necessity.
KIM BROWN: This isn't a luxury.
TIM MCNICHOLAS: Kim Brown didn't even a formal complaint was an option. She was too busy navigating an insurance maze for coverage of a specialty lightweight wheelchair-- a battle that lasted more than two years.
KIM BROWN: They just move on with their day where we're stuck.
TIM MCNICHOLAS: But Brown had someone in her corner. She says an executive with a wheelchair provider landed a meeting with a Blue Cross executive and convinced them to cover the chair.
KIM BROWN: A lot of people don't have an advocate for them.
TIM MCNICHOLAS: Even with an ally, a denial means a long and frustrating appeals process. After multiple appeals, the claim is sent to an outside agency for external review. If a denial is overturned in that phase, the patients have often already struggled for months, sometimes more than a year in a broken wheelchair or loaner that doesn't fit.
ABLA GHARIB: The loaner was only temporary, and it belonged to the wheelchair company. So eventually they would have taken it back.
TIM MCNICHOLAS: And when it comes to laws and accountability, those waters can be murky at best. Even the legislators we reached out to were short on solutions. And some struggled to explain what the state does to crack down on wrongful denials.
BOB SHEA: We understand that they have to have the right to deny unreasonable claims. And nobody is saying that they shouldn't have that right. But there has to be a consequence when it's blatant and obvious.
TIM MCNICHOLAS: One tool the state does have-- market conduct exams or reviews of insurance companies. But despite all those complaints we found, the market conduct exams on Blue Cross Blue Shield of Illinois make no mention of wrongful denials on medical necessities.
The state did find they took too long to decide some claims and didn't provide a written explanation for delays. The fine-- $320,000 in 2018, Blue Cross Blue Shield of Illinois' parent company profitted $4 billion that same year.
PATRICIA ROON: There's patients like Martina who go every single day dealing with things like this.
TIM MCNICHOLAS: Shortly after Martina's second denial, her dad lost his job due to the pandemic. They're now on a new insurance plan with Blue Cross Blue Shield National.
What's your favorite color?
MARTINA ROON: Black, white, and pink.
TIM MCNICHOLAS: When the pandemic slows down, they'll try again with their new plan, which will need a new doctor's evaluation, a new claim, a new challenge. And all Martina can do is keep pushing.
Despite our repeated requests, neither Blue Cross nor the state's insurance department would agree to sit down with us for an interview. But that won't stop us from continuing to investigate. If you've had a problem with any insurance company denying a claim on a medical necessity, I'd like to hear from you. Tim McNicholas, CBS2 News.
- All right, thank you, Jim.