In reversal, insurance plan will cover boy’s prosthetic

Introduction

A Michigan health insurance plan will make a one-time exception and cover a $30,000 prosthetic arm for a 12-year-old boy after his denied claim became a national story cited during the Senate health care debate.

The Huffington Post Investigative Fund reported two weeks ago that Benjamin French, who was born without a right arm, was ineligible for reimbursement because he had exhausted a lifetime maximum benefit for prosthetic devices. The report was part of the Investigative Fund’s ongoing coverage of how the health industry handles insurance claims.

The boy, who has three siblings, has needed over time seven prostheses since he was five months old. After Benjamin was fitted with the most recent arm, the French family learned that the claim had been denied by Blue Cross and Blue Shield of Michigan. The nonprofit insurer administers the health plan of the Michigan Conference of Teamsters Welfare Fund, which covers the French family.

It would have cost Benjamin’s parents more than half their combined annual income to pay for his new arm. Sen. Debbie Stabenow (D-Mich.) discussed the family’s situation during the floor debate in the Senate Nov. 21, calling on lawmakers to “eliminate those lifetime caps that get in the way of a 12-year-old boy being able to have the artificial arm that he needs … so he can lead a normal life.”

Just before Thanksgiving, Benjamin’s mother, Kristen French, received a phone call from a Teamsters representative, who said the union had authorized a one-time exception to the lifetime maximum payment. The French family later received a letter dated Nov. 25 from the Welfare Fund confirming that its board of trustees had voted to cover 75 percent of the price tag.

It is unclear how the insurance plan will handle Benjamin’s future prosthetic needs.

“They would not even talk to me before this. They just kept saying, ‘There is nothing we can do,’” French wrote in an e-mail to the Investigative Fund. “Amazing how media coverage can change their attitude.”

Helen Stojic, a spokeswoman for Blue Cross and Blue Shield of Michigan, declined to comment on an individual case. She indicated that the Teamsters fund set the insurance plan’s lifetime cap on prosthetic coverage. Blue Cross and Blue Shield “generally does not have separate maximums on prosthetics” in its health plans, she said.

Richard Burker, executive director of the Teamsters fund, said the reversal in the French family’s case was a one-time exception and does not signal a policy change by the union’s insurance plan. The plan’s caps on prosthetic coverage will continue, Burker said.

Editor’s note, Dec. 3, 2009: Asked how the Teamsters Welfare Fund sets annual and lifetime coverage limits, Burker said, “I can’t tell you what is in the minds of the trustees when they formulate the plans and benefits.” The Michigan Conference of Teamsters Welfare Fund made available new information Thursday about its health benefit plans. Richard Burker, executive director, said in an e-mail that on November 24th the Teamsters Fund Trustees increased the lifetime cap on prosthetic coverage in those few plans that still maintain a separate dollar maximum for prosthetic benefits, by adding another $30,000. Any such member who hit a lifetime cap during 2009 will be credited up to $30,000. Burker said it was inaccurate to report that he had characterized the Teamsters Fund’s decision as a one-time exception for Benjamin French. He said that he is prohibited by privacy laws from discussing an individual case, but that the Fund administers its health plans uniformly and does not make one-time exceptions.