Quadriplegic Raleigh woman wins insurance battle for wheelchair, now fights for change

News & Observer (Raleigh, NC)

Jul. 9--Ali Ingersoll is paralyzed from the chest down after a diving accident in 2010. She has limited mobility in her hands and uses a powered wheelchair.

For years, Ingersoll told The News & Observer, this has meant working and struggling with insurance to get the equipment she needs to live.

Ingersoll, a financial day trader, uses Blue Cross Blue Shield of North Carolina as it is one of the few left in the state that still offer policies under the Affordable Care Act.

She doesn't qualify for Medicaid or Supplemental Security Income, as her income is too high, so she pays for insurance costs and private care out of pocket. With deductibles and out-of-pocket maximums rising over the past few years, Ingersoll said, those out-of-pocket insurance costs now come out to just short of $13,000 a year.

She has used her fully-powered wheelchair for five years, and was eligible for a replacement this year. So she requested insurance coverage to purchase one.

However, one part of the new wheelchair -- a seat elevator that raises and lowers the chair -- was denied, as it wasn't deemed medically necessary. The elevator adds about $5,000 to the $29,000 retail cost of the chair.

Ingersoll appealed the decision, and said she sent in over 70 pages of documents from her general practitioner, physical therapist and medical supplier to argue that it was necessary for her.

But the response she received was another denial.

"Seat elevators for manually and power operated wheelchairs are considered not medically necessary," read a portion of the response she received from Blue Cross NC. She posted it on her blog.

"These items are considered a 'convenience' and not medically necessary in the sense that they do not serve a specific therapeutic purpose, even though they may contribute to a patient's independence or ability to assist caretakers in transfers, repositioning, or other aspects of movement during the performance of assisted daily living activities."

Ingersoll contended that the seat elevator was necessary, as it makes tasks like using household appliances and opening doors easier -- and it can be dangerous if she has to lean over and risks falling out of her chair.

"When I'm alone, I can't get up to my microwave to cook food, I can't open my refrigerator door, I have to raise my seat elevator up to open the front door. I have a sink where I have to be elevated," she said.

In early June, she sent the case to the NC Department of Insurance for external review. She included pictures of how she would use the equipment in her house. She sent letters to the CEO of Blue Cross NC and called local news outlets.

She shared her experience in a Facebook group and said hundreds of comments appeared from others who had similar issues with their insurance providers.

Weeks later, Ingersoll received a phone call and a letter from Blue Cross NC. She had been approved.

"This administrative decision is based on the individual merits of the specific case," the letter read. "This approval should not be considered a precedent for future or similar services."

She said her victory left her simultaneously excited and angry.

"What changed? I'm tenacious, I'm a pain," she told The N&O. "I'm pleasantly persistent. But it made me enraged."

In an email, Blue Cross of NC spokesperson Laura Eberhard told The N&O:

"Blue Cross NC follows an extensive review process, in which all appeals are carefully considered based on our medical policies. This process includes both internal and external reviews. It is important that we follow this process for all members. This process was followed in Ms. Ingersoll's case and we are grateful for the opportunity to serve her."

Eberhard also sent a link to an explanatory blog of Blue Cross of NC's appeals process, which details how members can avoid having a claim denied and how to file an appeal.

'It's a battle every single day'

What made Ingersoll angry, she said, is that this kind of experience has become common for her and others -- and many people can't take the time to argue for the necessity of the equipment and push through multiple appeals and review processes.

"The challenge in the disabled community is that people don't have time and a lot of people don't have the family and supports to do that," she said.

"I'm trying to shed light on the fact that people think that once they get a denial, that's it. But that's not true."

In the past, she's gone to external review after getting denied for a specialized stationary bike that uses electrical stimulation to help paralyzed people exercise. After 16 months of work, she said, she received the full coverage to pay for it.

"When paying for insurance," Ingersoll said, "who is to tell you what is necessary for you?"

Alan T. Brown from the Christopher and Dana Reeve Foundation, a quadriplegic since 1988, told The N&O that this issue is common for people with disabilities.

"Insurance companies don't realize the healthier they keep us and give us what we need to function, the less they're going to need to give us in the future," he said.

Brown, who lives in Florida, uses an eye-level wheelchair. "The difference that it's made in my life for these past 15 years is amazing," he said.

However, he said he's gone through reviews and appeals over and over again. Getting equipment paid for, he said, is a "nightmare."

"It's a battle every single day," he said. "And sometimes the battle isn't worth fighting and you just end up paying for it."

Ingersoll said she spends about three hours a day working on insurance issues now. But she requires multiple hours of caregiving a day and has nerve pain that sets in and makes it harder to manage work, so she only has so many workable hours per day.

So, she said, she has to be efficient.

Moving forward, Ingersoll said she wants to work at getting insurance coverage for other equipment and full-time home care -- which she said takes up over half of her budget every year. She hopes her work will lead to change for herself and others.

She's also made it a mission to keep a blog, on her Quirky Quad website and PushLiving magazine, in which she often tells about her self-advocacy and gives advice to others. She likes to say that she "fights for the underdog."

"There are so many medical things in a day that sometimes it just takes all your energy to wake up in the morning," Ingersoll said. "But I really just get pure joy when I see somebody win a battle."

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