AUSTIN (KXAN) — For 25-year-old Jeff Butler, his wheelchair equals independence.
“I like to refer to it almost as my legs. Some people go, ‘Oh you’re getting a new wheelchair, that’s like a new pair of shoes right?’ And I’m like, it goes beyond that.”
Without his chair, he couldn’t get around, couldn’t have a job and couldn’t represent Team USA as a wheelchair rugby Paralympian.
“It’s everything, it’s an extension of myself.” When he was 13, Butler was in a car accident that left him paralyzed, using a wheelchair ever since.
He recently got back from the Paralympics in Rio, only to continue fighting an ongoing challenge at home, getting approved for a new wheelchair he needs to live his everyday life.
Butler’s most recent wheelchair, which he paid for out-of-pocket five years ago, needed to be replaced. He says scratches and wear and tear on the frame compromised the structural integrity of the chair. So much, that he was nervous to use it during his travels to Rio.
Several months back, he started the process to get a new chair, this time going through insurance. He worked with National Seating & Mobility Austin, who helped him get fitted for a chair as well as started the process to bill the insurance company Humana.
Shortly after they submitted the claim, Humana denied it as not medically necessary. Butler appealed the denial with backing from his occupational therapist at Seton Brain & Spine Recovery Center, Eric Lantz.
Lantz wrote a “Letter of Medical Necessity” to Humana, saying the chair was over five years old, in need of replacement and that the warranties for the chair expired. “His was quite old and worn out,” said Lantz. “Jeff puts a lot of wear and tear on a chair, which is a good thing — we want people to be out and active.”
But Butler was denied again.
As part of their reasoning, Humana told Butler that the cost of a manual chair replacement is more than the cost of repair. However Butler says the insurance company has never actually seen his old chair, and isn’t sure how they made that conclusion.
“It’s been like a bad dream. Every time I call Humana it’s like, alright here we go again. I start in grievances and then I get to the medical team and then I get to the intake team and then I go back to grievances — and no one has any answers for me,” said Butler.
Butler says he wasn’t expecting to get all the upgrades he was requesting on the chair funded, but was hoping to at least get money for the base model, which can run around $3,500.
Unfortunately, his case isn’t unique.
“I’m not surprised, it happens all the time,” said Lantz. “One of the aspects of my job here is doing complex seating clinics where we work with a vendor to order a wheelchair for a client, and it’s really just getting harder and harder to get really custom chairs funded these days.”
Lantz says the insurance process can be even more frustrating for people who need more technologically advanced power chairs.
“There’s a lot of high-end equipment and if people don’t have access to it, they’re going to be confined to their homes, maybe confined to bed,” said Lantz. “It’s a real shame there’s these things that can improve their quality of life and allow them to do the things they want to do, but there’s a gap between the funding. And either patients don’t get it or they’re paying out-of-pocket all this money, when they really can’t afford it.”
In some cases, people in the United States have resorted to crowd funding to pay for the wheelchairs they need to live productive lives.
With Butler’s permission, KXAN has been in contact with Humana about the case. A media representative said they would do some research on the specifics, but ultimately sent back this response:
Protecting our health plan members’ privacy is an important priority. We always work diligently to resolve our members’ issues. Owing to federal privacy laws, however, Humana is prevented from commenting on particular circumstances involving our members, because those circumstances must by law remain private.”
Butler has since paid for his new chair out-of-pocket, but is holding on to hope that the insurance company will refund him.