Parents Seek Benefits Through Letter Writing Campaign

Benjy has not yet exhausted his annual or life time coverage limits, Margulies says.

But Aetna told the Margulies family it would stop paying for skilled nursing because it believes skilled nursing is not medically necessary.

Aetna also has told the Margulies family that a 60-day contract limit on therapy applies to the forms of therapy that Benjy is receiving, Margulies says.

Margulies contends that Aetna has not examined Benjy and has not produced any justification for cutting off coverage for skilled nursing care, and he argues that the therapy Benjy is receiving is more like chemotherapy, which Aetna would cover for more than 60 days, than like ordinary physical therapy.

An Aetna case manager said the 60-day limit on therapy benefits would not apply to Benjy, and Margulies notes that Aetna itself waited for 5 months before moving to cut off therapy coverage.

Because of the assurances that Aetna would cover Benjy’s therapy, “we chose to n6t apply for government benefits for Benjy,” Margulies says. “Had we not been misled in that way, we could have gotten Medicaid (which takes 60 days, in North Carolina, to approve) to provide a seamless transfer and be sure that Benjy was covered at all points.”

Now the Margulies family is applying for New York state benefits for Benjy. The family is asking Aetna for coverage for skilled nursing care while the application for state skilled nursing care benefits is pending, to avoid a gap in care, Margulies says.

About 22 hours after the Margulies’ news release appeared on U.S. Newswire, Aetna agreed to pay for 10 hours a week of nursing care for another 3 months, Margulies says.

Margulies is a lawyer. In 2003, he and his brother-in-law launched a successful, Web-based campaign to “draft” Wesley Clark for the race for the 2004 Democratic presidential nomination.

Although Cynthia Michener, the Aetna spokeswoman, says she cannot discuss the details of Benjy’s case, she did comment generally on conflicts over policy coverage limits.

“No matter how strongly we may wish to act on our personal desire to provide unlimited benefits for any one member, we cannot do so in fairness to all of our members who access benefits in accordance with their medical plan guidelines,” Michener says in a statement. “These limits are put in place to create affordable health benefit plans that employers can purchase to provide the maximum amount of coverage for as many employees as possible.”

Aetna offers 2 levels of internal review and at least 1 level of external review for members who disagree with the decisions made about their cases, Michener says.