Health Insurance Denial Compounds Grief

After his wife's stroke, a reader runs into payment problems.

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After reading my article "The Art of Complaining," in which I mention that Aetna incorrectly rejected one of my claims, reader David Porinchak wrote U.S. News a letter about the trouble he'd been having with the company. His wife, Patricia Porinchak, a reading specialist, had a debilitating stroke just before Thanksgiving last year. She passed away at age 73 on December 22 in Apex, N.C.

David Porinchak's grief was compounded by the fact that Aetna denied payment for the ambulance that drove his wife to a nursing home as well as for her skilled nursing care, which had been recommended by hospital stroke specialists. He wrote "with tears and pain intensified by the cruel, insensitive treatment by Aetna at this sad time in my life."

The letter was heartbreaking. It came with copies of documents from Aetna, which stated, "We will not pay for these services because ambulance transportation is covered only if you could not have used another means of transportation without endangering your health. The transportation you received was not medically necessary and is not covered by Medicare or Aetna." (The letter was addressed to Patricia Porinchak over two weeks after her death.)

When I called David Porinchak, he said that the ambulance was indeed medically necessary, as specified by his wife's doctors.

To get to the bottom of what happened—and to determine if Aetna had, indeed, made an error—I spoke with Aetna spokesman Walt Cherniak. Regarding the skilled nursing care, he said that in this case, it is up to Medicare to cover hospice-related expenses. For more information on Medicare hospice benefits, he suggested this online pamphlet. "We denied the claim because it is appropriately filed with Medicare," he said.

But the ambulance denial was in error. Cherniak said that Aetna initially had not received the proper information from the hospital that would have clarified that it was medically necessary. While emergency ambulance transportation is covered immediately, nonemergency use, which it was in this case, needs to be preauthorized by a doctor or facility, he explained. Once Aetna received that preauthorization information, then the claim was reprocessed on March 6.

The lessons from this situation aren't that easy to sort out. It would have helped if the family had had more time to anticipate the hospice care and research insurance options, but, as with many medical emergencies, there was not much time to plan ahead. David Porinchak's complaints (along with the help of his daughter) to Aetna did register, though, and helped result in the ambulance denial being remedied.

Over the phone, David Porinchak made the point that many of us will need to rely on ambulance transportation, and hospital care, at some point in our lives. It would be nice if our insurance companies could make paying for it as simple as possible.

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