Insurance Forces a Deserving Client to Accept a Lesser Life

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I was contacted by a Nurse Care Manager from Portland, Oregon a few months ago to meet her on site at a client’s home in my county to discuss home modifications to help improve his life at home after a severe work injury that left him missing a portion of one arm and one leg due to a high voltage electrical incident and burns.  I was honored to meet with Care Transitions Northwest LLC as well as the client, his wife, and his daughter who was managing the case for her father.

The client had a step up into his master bathroom, and the components in the master bath were all “spec house” size, with no reasonable way to simple “swap out” fixtures for U.D. (Universal Design) products without needing a reconfiguration of the bathroom’s separated vanity sink area, adjacent walk-in-closet, adjacent closet behind the bath in the guestroom, etc. to make the floor area work better for his mobility challenges.  There were going to be some wall framing changes required to make this work, including removing the step up into the bathroom where he was regularly having his “night leg” FALL OFF when trying to navigate the restroom at night, among other issues he dealt with.

I had, on site that day, received agreements on how reconfiguration would work best and could be accomplished to make his home life more successful.  The daughter, wife, and NCM all were excited about my ideas, and I was ready to get under contract with the client and do this wonderful project that would help him be safer and more independent in his home.  My recommendations included other areas of the home, including hall railings, the back stairs, entry from the garage (where there were steps), etc.  I was ready to supply the NCM with our home assessment full written 4-5 page summary including going back to the home to get photos and dimensions, sketch solutions, and offer our professional input to help the client with his challenging home situaiton.

Here is the first email I received from the NCM after our site meeting:

Your input and insight was very helpful and clear.  I appreciated your patience and time.  I had some insights after this meeting with you, the doctor, Mr. XXXX and  his family, and thinking about an overall plan. I do have concerns about the insurer paying the costs of a large modification that would include so much structural change.  I need to get clarity on  the state WC jurisdiction that applies here…  Sometimes state administrative rules provide more or less benefit in this area – so that could come into play.  Another  key factor will be how much financial responsibility belongs to the WC insurer if an individual has to move to an assisted living environment or skilled facility because of the injury. I believe I need to prepare with some cost comparisons including:
1) A fall resulting in hospitalization, 2) surgery, 3) temporary SNF for recovery, as well as 4) home modifications.
Have you had any experience with using funds from VA  benefits to augment payment for home mods? – VA does have a home modification benefit – I need to look into options on this – Sharon was not certain about the type of VA  benefits he is eligible for, but if we can bring in other financial participants to mitigate some costs, it may make the claims adjuster more amenable.

Why is helping someone that clearly deserves it so difficult?  Why, when we pay in SO MUCH to the insurance system over our years, careers, and life, is it like pulling teeth to ask THEM to STEP UP to the plate when it’s their turn to return the favor, and CARE for US?

Two months later , after the NCM had done MUCH advocating and research on his behalf, the call I received this week stated that all she can get approved (and the client has agreed to it appears, just to get SOMETHING done) is to do NOTHING to his master bathroom, adjacent to their own bedroom where he’d like to be sleeping in the same bed with his wife.  What the insurance company has agreed to do, was to pay for a “walk in tub” in the GUEST HALL bathroom, in place of the existing standard tub/shower.  HOW AWFUL!!  

This minimal guest bath is a spec house standard 5′ x maybe 8′ maximum room, which is typical to allow the 30″x60″ tub/shower at the back of the room, the 18″ clear each side of center line of the toilet immediately adjacent, and the remaining 42″ of counter and cabinet base with a single sink.  In this layout:

1) An in in-swinging 2′-6″ door when open, won’t even allow the base cabinet drawers to be opened completely.

2) A 30″x60″ space to solve a walk-in tub could be quite problematic with certain tubs related to the “door” opening location.

3) The toilet could be jutting into that space where you’d access the tub comfortably (with more space).

4) That in-swinging door, when someone falls INSIDE the bathroom, could be (and likely is) BLOCKED from being opened in an emergency by the person on the floor inside!!

I’m saddened by this outcome.  I truly wanted to be able to help this man.  I don’t know what I can do to make a difference in a situation like this.  It hurts me to see him suffering (and his family / caregivers with him) the way he is at home to get around and through a normal day in his life.  He DESERVES BETTER.  He deserves to feel safe.  He deserves home modifications and a thoroughly thought through re-design of his spaces that will EMPOWER him in his daily life.  His current situation needs much more than just a new tub (if it even fits and works in the un-modified floor plan the insurance company is thinking is acceptable).  

I can’t lobby for a living, I don’t know how to change the rules and the laws, nor do I have the time or financial freedom to pursue things like that.  I have to keep my day job.  But a situation like this, and the “big brother” insurance company minimizing his needs and situation after he was HURT ON THE JOB is simply LUDICROUS.  Where can we go from here?  How can we really help??? (…frustrated…)


Photo Credits –
Old Prosthetic Leg:
Walk-In Tub:
Pulling Your Hair Out:

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