Health insurance denied medical claims for a 17-year-old's traumatic brain injury. His family found an unexpected workaround

During a basketball game in August of 2024, Marcus Kennedy, a seemingly healthy 17-year-old from Anchorage, Alaska, went into cardiac arrest.

“I heard my mom just start screaming,” Marcus’ dad, Brandon Kennedy, told NBC 5 Responds. “And I looked up and Mark was on the ground and he started convulsing.”

Doctors later determined it was brought on by an unknown genetic heart defect. Marcus survived, but he suffered a traumatic brain injury. By mid-October 2024, treatment led him to Chicago’s Shirley Ryan Ability Lab, and Marcus’ condition slowly started to improve, Kennedy said.

But several weeks later, Kennedy said he received unexpected news from his insurance company, Aetna.

“They said they’re not going to pay for them anymore for inpatient,” Kennedy explained. “They think outpatient and the rehab will be sufficient for his care.”

When Kennedy asked Aetna when the payment period ends, Aetna, he says, told him “tomorrow,” giving the family 24-hour notice to find a new place for their son to recover.

The out-of-pocket costs to keep Marcus at Shirley Ryan was shocking to the family, Kennedy said.

“So if you prepaid for a week, it’s $32,000” Kennedy went on to explain. If the family didn’t pre-pay for a week of care, Kennedy said, the cost would be even higher — approximately $56,000 per week out-of-pocket.

Kennedy then went back to Aetna to submit an appeal.

Kennedy recalled the phone call with an Aetna representative, telling NBC Chicago, “The appeal, even expedited could be up to a week,” he said. “What am I supposed to do with him during this week that you guys aren’t paying? And the answer I got was a lot of silence and then repeating the same thing about the appeal.”

While he started the appeal process, Kennedy says he also called his employment union’s health trust, which has the ability to review and overturn Aetna’s denials.

The move proved to be a game-changer.

With help from Kennedy’s union, Marcus’s continued stay at Shirley Ryan was covered until he moved to another rehabilitation facility for the next step in his recovery process.

After Kennedy’s union became involved, Aetna told NBC 5 Responds: “Aetna is committed to helping our members receive high quality appropriate care at the right time. That means Aetna clinicians regularly review the care our members receive and communicate with the treating providers to promote high quality, evidence-based care. Aetna clinicians are currently working with the facility to assist this member. If a member or provider does not agree with a coverage decision, they have several options, including a formal appeal process.”

After the experience, Kennedy says he’s learned an invaluable lesson about navigating the health insurance system. “Just keep fighting and don’t go quietly. Don’t just take their first answer as law. You have the resources are there. They may be hard to find, but they’re out there somewhere.”

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from NBC Chicago https://ift.tt/HOQptBK