Medical Insurance Lawsuit Filed after Aetna Cuts Coverage

A couple has filed a medical insurance lawsuit on behalf of their disabled 15-year-old son. Long Island residents John and Lisa Brower filed their lawsuit after Aetna cut coverage for their son’s home care, saying the company has served a “death sentence” on the teen.

After a number of years of reducing coverage for the necessary 24-hour home care, the couple has taken their case to court in hopes of pursuing compensation for lost coverage and financially devastating healthcare costs.

According to New York Daily News, the Browers recently filed the lawsuit in Manhattan Supreme Court, after the appeals process with Aetna failed. The couple claims their son, Jake Brower, has required round-the-clock care because of seizures the boy suffers on a daily basis. When a seizure occurs, Jake’s blood pressure and heart rate go down to a dangerous level, requiring treatment by trained medical staff.

Medical misdiagnosis led to permanent disability

At the age of five, Jake underwent surgery to remove a cyst from his brain. A medical misdiagnosis of an infection after the procedure left Jake confined to a wheelchair and suffering from the daily seizures. Jake now wears braces on his arm, neck and legs and requires feedings through a tube. He also has three shunts inside his brain, which restricts his mental abilities.

Since that time, John Brower retired from the New York Police Department and Lisa Brower left her job as a surgical technician to care for Jake and his three siblings full-time. Originally, Aetna provided coverage for full-time home nursing care to monitor Jake’s condition and attend to his medical needs. However, in 2006, the insurance company reduced care coverage to 12 hours a day and then to eight hours a day in 2012.

At first, the Browers didn’t complain about the reduction, since Jake was in a school during the day that provided the medical care he needed. When Aetna refused to provide coverage for home care on the days Jake stayed home sick from school, the couple sought legal help. Lisa Brower told the New York Daily News, “He needs 24-hour care. I just want what he needs…We’re not asking for anything more than what he needs. I can’t be his 24-hour nurse…I’m a mother, not his nurse.”

Insurance company calls nursing care a “matter of convenience”

Aetna has countered the allegations by the Browers, stating 24-hour care was more a matter of convenience for the family, rather than a medical necessity. However, Jake’s epilepsy physician stated it was “medically compelling” for Jake to have 24-hour medical care. Lack of that care could put Jake in “jeopardy for early mortality.” This was particularly true in light of the fact that his condition actually worsened in 2013, with the formation of a new mass in his brain that increases the seizure frequency.

The Browers spent a number of years trying to settle their case through the appeals process provided by Aetna, before filing their lawsuit. This appeals process is available to every health insurance customer and should be spelled out in the insurance policy. An interior appeal process directly to the company is usually the first step. If that appeal is denied, consumers also have the option to file an external appeal with a third party.

If the appeal process does not result in a positive decision for the consumer and patient, a medical insurance lawsuit may be the next step. In this case, it is important to hire an attorney experienced in the complexities of insurance law to handle the case, to ensure the best possible results. The Browers have done just that, filing a claim for an unspecified amount that some estimate could be in the millions.