A Navy Captain's Increasingly Absurd Fight Against Military Insurer to Pay For Disabled Daughter's Physical Therapy

Categories: Healthcare

KaitlynSamuels.jpg
Change.org
The Samuels family, with Kaitlyn front and center
When Kaitlyn Samuels was 4 months old, her parents, Mark and Jennifer, worried that she couldn't reach for her toys. Doctors initially assured them that it was probably normal, but after two months brought little improvement they ordered a battery of neurological tests that revealed Kaitlyn had a very rare and very serious brain malfunction.

The years since then have been a struggle, as Kaitlyn has suffered the effects of epilepsy, cerebral palsy and all sorts of related complications. She can't speak or walk by herself. Her food has to be blended into liquid form because she can't chew. Her brain is frozen in perpetual toddlerhood.

Kaitlyn also suffers from severe scoliosis. Left unchecked, the condition would get progressively worse, with the increasing curvature of the spine diminishing lung capacity, popping joints out of socket and eventually killing her by crushing her internal organs. It can be treated with physical therapy, but traditional methods didn't work for Kaitlyn; she would grow bored and shut down, rendering the session worthless.

In 2009, the Samuels found a solution at Rocky Top Therapy Services in Keller, where the family was living. There, Kaitlyn is placed on a horse that is then led in a circle by volunteers and Suzanne Sessums, the family's physical therapist. The horse's breadth stretches Kaitlyn's legs while its movement works her hips and pelvis. All the while, she has to keep herself upright, strengthening her back and neck muscles. More important, Kaitlyn enjoyed being on the horse and stayed engaged for the duration of the twice-weekly, 30-minute sessions.

Mark Samuels is a captain in the Navy, and the treatments were paid for through TRICARE, the health plan for Department of Defense employees -- at least they were for nearly a year, until TRICARE abruptly decided the treatments count as hippotherapy and would not be covered under the Samuels' health plan.

What's ensued for the Samuels has been a two-year battle against a Kafkaesque bureaucracy. When it determined Kaitlyn's therapy wasn't covered, TRICARE decided the Samuels should repay the insurer $1,300 for several month's of treatment they hadn't previously objected to. The Samuels filed an appeal, claiming their daughter was simply receiving physical therapy that happened to be on a horse, and that the treatments should be covered.

The appeal wound its way through the byzantine Department of Defense appeals process -- at one point in the fall of 2011, hearings were delayed for two months because Congress had not passed a federal budget -- before the family wound up in a Dallas courtroom to argue their case.


My Voice Nation Help
28 comments
thenavywife22
thenavywife22

Wow on so many levels.  The first level is that this type of therapy is not covered.  I thought this was approved. At least I think it is for autism.  The second Wow is that a Captain who is making close to $10,000 a month cant pay for his own horse back riding lessons.  Sorry, but if this was an E4 or other lower enlisted who couldn't afford this I would feel badly. 

lynnj0750
lynnj0750

This is MURDER! We have been subject to the same failed process! Why don't military members have the same protections under the PPACA act? Shame on our government and all those involved. Shame on those who reverse, deny and then arbitrarily and capriciously discriminate against sick beneficiaries like myself and Kaitlyn Samuels. My husband no longer proudly serves his country but counts the days until he may retire knowing that every day his family is being withheld proper medical treatment.I have been in contact with not only the reporters who have done an amazing job shedding light on these issues but also the Samuel family. I pray to god that not only does the care in question (that is, only questioned by Tricare/DoD lawyers) will finally be covered but that the person working on our DoD IG investigation will discover, that above and beyond specific care, (that Tricare makes it impossible to navigate or to be successful in arbitrating) that the DOD IG investigation will discover that Tricare (through contractor like Healthnet) is arbitrarily and capriciously delaying and/or denying all care/claims to beneficiaries who exercise their right to appeal. That this will shed light on the flawed appeals process, the flawed process in which lets Tricare contractors twist the words in federal regulations to defer and ultimately deny legitimate medical claims. A flawed process that lets Tricare decide the ultimate faith of life or death, regardless of an outcome of the appeal hearing.If this were any civilian insurance company this would not be tolerated or allowed. The PPACA act protects civilians but leaves our military families at the mercy of the flawed process. It lets them die. This is not about the specific appeal or the Samuel's need for physical therapy for their daughter. It's about flaws in the system. It’s about Tricare and their contractors making mistakes but nobody taking accountability.Fix the process that lets Tricare official's like Mr. O'Bar play GOD! Do you really think that the Samuels went through a three part appeal, which included spending more than $5,000 on legal representation over $1,300 worth of claims if it wasn't about what is morally and ethically wrongdoing? Please pray for the Samuels and families like ours, that the Armed Forces committee will get involved and will hold Tricare accountable for breech of contract. Hopefully they will amend legislation and/or will support new legislation that protects our beneficiaries. Legislation that doesn't allow Tricare and their contractor(s) (ie: health net) to twist and manipulate it to deny medically necessary care. Legislation that will give our military members the same rights and protections that give every other American under the PPACA act.

Donna Streetenberger
Donna Streetenberger

Excellent article. Billion dollar health insurance executives can't afford to pay for physical therapy? What ARE they spending the money on? Their games are so tiring. We send them outrageous premiums and all they can say is "coverage denied" and then send a bill. Screw them.

jennifersamuels
jennifersamuels

I just want to point out for the record that this has nothing to do with Obamacare. Tricare has been around for years and military families have been dealing with this type of problem the entire time. We just finally said enough!

Myrna.Minkoff-Katz
Myrna.Minkoff-Katz topcommenter

OBAMACARE MYTHS DEBUNKED:

 

Q: Will I be forced to change insurance? A: No. That’s a MYTH. If you’re satisfied with your current plan, you can keep it.

Q: Will illegal immigrants now be covered by our money? A: No. That’s a MYTH. In fact, undocumented immigrants are expressly excluded from coverage. Only legal immigrants who pay their share will be covered.

Q: Will I go to jail or be harassed by the IRS if I don’t have health coverage? A: No. That’s a MYTH. In 2014 Americans (except Native Americans, Inmates or those with religious objections) will be required to have health insurance or pay an annual penalty. True. However, the law prevents the IRS from using levies, liens or seizing property. Additionally, the IRS cannot impose criminal penalties (such as time in jail).

Q: I heard there was going to be a 10% tax increase across the board. Is that true? A: No. That is a MYTH. While there will be tax implications, most of the biggest changes apply to medical manufacturers, insurers and pharmaceutical companies. In fact, some Americans may see no changes at all. Tax changes that could affect average individuals include …

A 10% sales tax on indoor tanning (yes, really)A 0.9% increase on the Medicare tax rateA 3.8% tax on investment income for individuals earning more than $200,000 and households earning more than $250,000Taxes on high-end or “Cadillac” health care plans (this excise tax would not begin until 2018 and only apply to insurers of plans that exceed $10,200 annually for individual coverage, or $27,500 annually for family coverage)

Q: Will the government now pay for abortions? A: No. That’s a MYTH. The law already in place which prevents using federal money to fund abortions (except in cases of rape, incest, or danger to a woman’s life) is not being altered.

Q: Will I have to pay for other people’s abortions? A: No. That’s a MYTH. Those opposed to abortion will not be forced to assist in funding them. You can simply select a plan that does not offer them. This applies not only to people who may have objections to abortions on moral grounds, but also to those who simply have no reason to pay an extra premium for that type of coverage (such as women past their child bearing years or single men).

Q: Does the “Public Option” mean the government will run health care? A: No. That’s a MYTH … and a non-factor at this point. In fact, the “public option” did not make it into the final legislation that President Obama signed. THERE IS NO PUBLIC OPTION. Even before it was dropped from the bill, it was misunderstood to be government-run health care – wherein the government would make your health care decisions. Rather, it would have been government-provided insurance option to compete with private insurance.

Q: Will my Medicare benefits be cut in order to extend care to others? A: No. That, too, is a MYTH. Brooks Jackson, director of FactCheck.org, says that although the reform package includes $500 billion in “cuts”, it does NOT include traditional Medicare benefit reductions.

Q: Does this mean that “death panels” are now a reality? A: No. And they never were. This myth was based on misunderstanding of a provision in the original bill that required payment, by Medicare, for health care practitioner-led end-of-life counseling. This is not part of the law.

 

Myrna.Minkoff-Katz
Myrna.Minkoff-Katz topcommenter

Obamacare will eventually put an end to these horrible stories.  Health care is a right, not a privilege.

Fb2012
Fb2012

It works for Mitt Romney's wife. Why not for this little girl? 

JM64
JM64

Tricare (formerly CHAMPUS) is usually pretty good to active duty service members, this case, I think, is an aberration caused by some bureaucrat who doesn't like horses and now has too much 'face' involved to back down, even when it is the right thing to do.

TeddyBoy
TeddyBoy

As bad as things are for him and his family, at least the good Captain can be thankful we don't have single payer universal health care.

jennifersamuels
jennifersamuels

@thenavywife22Wow, I am not sure where to start....First of all this is exactly why we are trying to change this...for that E4 and others who cannot afford, not only the therapy, but the expenses of appealing the decision. Also, your 'theory" regarding healthcare benefits is flawed - i.e. if you earn enough to afford a treatment then it's not covered. My husband earned this health coverage and our daughter received a covered service: physical therapy. She in no way received 'horse back riding lessons" and no it is not covered for autism either. We ARE paying for our daughter's physical therapy now and we also started a foundation to help all those "E4s" to receive physical therapy utilizing the horse while we continue to fight to clarify the law.

RTGolden1
RTGolden1 topcommenter

 @Myrna.Minkoff-Katz Riddle me this:  "ObamaCare" is actually the Affordable Care Act, right?  Affordable.  Since the Act passed, the premiums for healthcare at the small business I work in have gone up 54%.  This has effectively taken my healthcare premiums from 5% of my gross pay to near 10%.  Next year's premiums are expected to go up 38%-42%, and 12.5% of my gross pay.  Healthcare is already my third largest monthly expense, after Child Support and Rent.  I'm not a $35k millionaire douchebag.  I live within a tight budget, don't run credit, and work my ass off to make ends meet.  I couldn't afford this year's increase, and next year's increase will mean a choice between dropping health insurance for myself or reducing what I can give my oldest son for college. (Which the Dems also claim is the 'right' of everyone).

President Obama, in the rush to pass something he could call 'Reform', caved in on every measure of the Act that would have helped those who really need it.  By allowing the public option to be taken off the table, he negated any possible 'affordability' in the Act.  He gave the insurance companies a deadline: "Raise your rates as high as you can as soon as you can, because in 2014, the government will have to approve any hikes in premiums."  To console the insurance companies for this inconvenience, he makes in mandatory to have insurance or face penalties, thus giving the insurance companies a captive audience.  I guess this is the old adage with a new twist: The Republicans will rob you blind, The democrats will make you too poor to rob, and President Obama, in the spirit of bipartisanship, makes it possible for both to do it to you at the same time.

ScottsMerkin
ScottsMerkin topcommenter

 @Myrna.Minkoff-Katz Here is 1 Fact I will give you, my healthcare cost more next year as a direct result of Obamacare passing, why is that?  My company and many others are passing the cost on to the employee by either raising the cost to the employee or choosing plans cheaper to the company that have lesser coverages or higher deductibles, so NO I cant keep my current plan if I like, my company is changing the benefits of the plans we have

RTGolden1
RTGolden1 topcommenter

 @Myrna.Minkoff-Katz Rights don't come with premiums, and aren't supposed to be better distributed to those with union membership than to those without.  Get your facts straight, until we have a single payer system, healthcare is a privilege, and ACA makes it an obligation.  It also makes it an obligation that is increasingly unaffordable for those who really needed the help ACA was supposed to bring.

ScottsMerkin
ScottsMerkin topcommenter

 @Myrna.Minkoff-Katz If this is what government healthcare is like, you can keep that shit.  I see the Shit by dad goes through at the VA and it a fucking joke too

WhiteWhale
WhiteWhale

 @Myrna.Minkoff-Katz Sorry Tricare (Champus) is government run.  This is an example of the hoops everyone is going to have to jump through when dealing with the government.

jennifersamuels
jennifersamuels

@ThePosterFormerlyKnownasPaul We had hoped if we won that Tricare would accept the judge's decision since he's actually on THEIR payroll! Boy were we wrong. Winning "allows" us to file a federal lawsuit. Would love to if it wasn't so expensive...

jennifersamuels
jennifersamuels

@Fb2012 The bottom line is that our daughter was receiving physical therapy using the horse as a tool. They refuse to even enage the discussion. My daughter's physical therapist as well as her neurologist testified at our hearing. No one from Tricare even watched one treatment session yet they say it's not physical therapy. Bottom line is the decision maker at Tricare is a former Navy pilot with no medical training.

jennifersamuels
jennifersamuels

@JM64 Actually not true. There was a class action lawsuit brought against Tricare by military families of autistic children this year. The families won! And this was not a hearing like we had it was a civil lawsuit so they MUST do as the judge directs. Well Tricare is NOT and is likely going to be brought back to court....My husband has been on active duty over 20 years. There are many problems with Tricare....

Myrna.Minkoff-Katz
Myrna.Minkoff-Katz topcommenter

 The republicans have you people brainwashed into believing Obamacare is "government-run".  Find the facts for yourselves and turn off FOX news.

jennifersamuels
jennifersamuels

@WhiteWhale @oakclifftownie Technically Tricare is not an insurance company as they pointed out to us. This allows them to not be held to any insurance regulations! A private insurance company could have never done what Tricare did. So Tricare makes the rules and they enforce the rules & are accountable to no one. They are worse than an insurance company....

ScottsMerkin
ScottsMerkin topcommenter

 @Myrna.Minkoff-Katz why so you can read your liberal flash cards to rebut anything I say?  thats all you are trying to do, you dont care what I actually know, you just want to paint me a horrible Fox watching right wing nut.  I wont let you do it

ScottsMerkin
ScottsMerkin topcommenter

 @Myrna.Minkoff-Katz I dont watch fox news, Ive told you this already and if you dont think government mandated doesnt mean its government run you are crazy.

Now Trending

From the Vault

 

General

Loading...