Melissa Scott’s plan was in motion. The Shirly Ryan AbilityLab in Chicago approved transferring her daughter, Carajean Goodchild, to their site, so they could try helping her regain full consciousness after her coma.
Scott packed her daughter’s bags and told her work she was heading to Chicago. The renowned lab represented a glimmer of hope for Scott, who for months had sat by Goodchild’s side, waiting for her to progress so the two could have a conversation again.
Then the call came.
“Suddenly, the insurance said, ‘No, we will not approve that (tranfser),’” Scott said in an interview with The Advocate. “We did peer-to-peer again, and again they said no. We did two appeals; they said no. Then, they have essentially told me there is no more appeals process.”
Scott knows her family’s case is no outlier. She’s aware she’s one of hundreds, if not thousands, of people fighting insurance denials as they seek improving their loved ones’ conditions.
She has tried filing complaints at the state level, only to reportedly be told the agencies don’t deal with UMR, a subsidiary of UnitedHealthcare, or that her husband’s employer could potentially overturn the denial.
Scott’s lawyer told her she could bring her case into the courts, but she knows the time and money that effort would require is likely excessive.
“It’s just a bit insane the hoops I’m having to jump through,” Scott said.
When reached for comment, a UMR spokesperson told The Advocate they could not comment publicly on a case without a signed HIPAA waiver. Scott filled a waiver for Goodchild, but UMR did not respond with comments on Goodchild’s case prior to The Advocate’s deadline.
‘Fighting every day for her’
Goodchild, 18, is undergoing treatment at Select Specialty in Victorian Village months after being involved in a July two-vehicle crash that killed her friend, Brian Winner.
She had been living in Frazeysburg with her family prior to the crash. She enjoys hanging out with friends, spending time with her dog, Mabel, and cat, Smokey, and listening to music, Scott said. She was considering a career in health care because she wants to help people.
Goodchild has been at Select Specialty for nearly three months. Before that, she spent about a month in a vegetative state before regaining minimum consciousness. Supporters have raised nearly $7,500 through GoFundMe for her treatment.
She can open her eyes, look around and seems to listen, but isn’t following directions or speaking, Scott said. Her family believes she is close to becoming more responsive but won’t extensively progress at Select Specialty compared to the lab.
“The end of (December) will mark five months since the accident — five months of feeling like you’re fighting every day for her,” Scott said.
For the past two months, Scott has researched areas in which she could place her daughter into a disorders of consciousness program that’s designed to help patients emerge to full consciousness.
She found Ohio State Dodd Rehabilitation Hospital, though she says it only accepts three patients at a time and Goodchild has not yet been approved.
The Shirley Ryan AbilityLab, however, told Scott on Nov. 26 that it would welcome Goodchild after her doctors and case managers told the facility about her case, she said. An admissions coordinator told her she would have to be at the lab three days a week and that Angel Flight could transport her daughter, among other expectations.
Scott’s back-and-forth with UMR
The lab, Scott believes, is the best fit for Goodchild’s treatment because of its experimental methods and processes to stimulate the brain. She saw a few of the lab’s videos in which patients regained full consciousness, despite their previous comatose state.
UMR, however, denied the claim Nov. 27, Scott said. According to Scott, the company did so because it feels Goodchild can’t perform three hours of physical therapy per day. Scott, a longtime nurse, insists that doctors must first treat her daughter’s mental state before helping her restore physical movements.
“Once we wake her up, then we can worry about physical,” Scott said. “I just keep feeling like people don’t understand that this is not traditional rehabilitation — like grandma got a new hip and now she’s going for therapy. This is all about being in a coma and how you emerge from that.”
Scott isn’t sure who at UMR is reviewing her daughter’s case. Scott suspects it could be nonmedical personnel doing so or that the company is using a specific checklist in its decision-making.
Some insurance companies outsource medical reviews to other companies that use medical guidelines to delay or deny care for patients, among other practices designed for profit, according to a CNN report.
“I think I’ve always known for quite a few years that there’s a major problem with our system and that it really is all about the dollar,” Scott said. “Somewhere along the way, we lost that it’s about the people and taking care of actual patients.
“There’s very few places that will take indigent patients, and if they do, the unfortunate thing is you’re probably getting some subpar care there. Not everybody has equal access to the best care.”
Scott’s fight comes amidst scrutiny at nation’s insurance companies
Scott’s fight for her daughter’s claim comes amidst heightened scrutiny and resentment among Americans towards the nation’s health insurance companies, particularly UnitedHealthcare. Soaring costs and costs and denials have fueled the outcry, which swelled following the death of UnitedHealthcare CEO Brian Thompson.
UnitedHealth Group, the health insurance unit of UnitedHealthcare, in a statement said it pays about 90% of medical claims and that “highly inaccurate and grossly misleading information has been circulated about our company’s treatment of insurance claims.”
Scott condemned the shooting but criticized the “dollar-over-care” model many critics say insurance companies follow.
“When you’re on this side and you’re fighting and fighting and you’re so frustrated and you just don’t know where to go next, I can almost kind of see where somebody might lose their mind a bit,” Scott said.
Scott expects to receive a formal denial letter from UMR soon. Once she gets it, she isn’t sure what next steps she’ll take, but friends have suggested contacting U.S. Rep. Troy Balderson’s or Gov. Mike DeWine’s offices for help. Her lawyer told her she could sue UMR, an option Scott said she might pursue.
Above all, Scott remains hopeful for an opportunity and just wants her daughter to receive a chance to build her mental and physical state back to what it once was.
“The first day I tried calling the insurance, they essentially were like, ‘Talk to your case managers,’” Scott said. “I get that, but I want someone to hear me. I want to plead her case somewhere. I want someone to hear it. She’s 18, there’s so much potential.”
Advocate reporter Josué Perez can be reached at jhperez@newarkadvocate.com.
Clinton Mora is a reporter for Trending Insurance News. He has previously worked for the Forbes. As a contributor to Trending Insurance News, Clinton covers emerging a wide range of property and casualty insurance related stories.