Rehab Runaround

An Insurer Dithers and an Addict Dies

Robert Payton was the kind of guy who could take care of business. A 42-year-old lawyer who handled real estate and construction cases, he was articulate, well-educated, and insured. So after Payton, who was also addicted to drugs and alcohol, accidentally overdosed and ended up comatose for 12 days in January 1998, he was determined to kick his habit.

Even before he left the hospital where he'd regained consciousness after his brush with death, Payton launched what became an extended campaign to get approval for inpatient drug rehabilitation from his insurer, Aetna/US Healthcare. According to his sister, Maureen Hussey, "he made between three and five calls a day. He even kept a journal of his notes."

But Payton's crusade to get the treatment that had been recommended by his doctors was ultimately for naught. He died of an overdose in his Manhattan apartment, halfway through one final letter to his insurer.

Robert Payton was "basically ignored," his sister says.
Robert Payton was "basically ignored," his sister says.

Now his mother, Delores Payton, is launching her own campaign, suing Aetna/ US Healthcare and two of its medical directors for $800 million on the grounds that the company violated state law and its own policies by denying her son benefits. The complaint charges the doctors with malpractice and accuses the company of being grossly negligent and acting with "willful disregard" for Robert Payton's life.

State supreme court Judge Herman Cahn is considering Aetna/US Healthcare's motion to have most of the charges dismissed because, according to a company spokesperson, "We don't believe those claims are recognized by the state of New York." The spokesperson also noted that Aetna paid for Payton's drug detoxification, but insisted that his policy didn't cover rehab.

If the full case does go to trial, it will be one of the few suits to scale the towering wall of legal protections surrounding managed-care companies. With regulation of the relatively young industry still in the works, most insurers have so far been exempt from liability by a law that was designed to protect employers. Payton's attorney, David Trueman, believes the case can dodge some of these legal protections because Payton purchased his insurance as an individual, instead of through an employer.

What happened after Payton bought his policy, as Trueman tells it, is a chilling example of how the all-too-common runaround can turn deadly. According to the lawyer, Payton was repeatedly denied inpatient drug rehabilitation treatment, though, as Trueman tells it, "there was no question it was covered in his contract" with Aetna. "The company "should have made a decision recognizing those benefits on January 25."

Instead, as Hussey describes it, the company repeatedly refused his requests for coverage and many times didn't return his calls at all. "He was basically being ignored," says Hussey. Undaunted— not to mention desperate— Payton continued to make calls and filed oral grievances with his insurer, and later filled out the company's official written-grievance forms.

Aetna's responses to these pleas seemed to shift over time. In a March 18 letter to Payton, one of the company's medical directors says he is writing "in response to the grievance you filed," but goes on to say, "We have no record of a request for you to receive substance abuse treatment or being denied any requests." (Trueman says Payton made his original request over the phone and was never asked to put it in writing.) A subsequent letter to Payton says he does have coverage for 30 days of substance abuse treatment per calendar year, but that Payton cannot request an appeal hearing, again because "there must first be a denial of coverage." In a later letter, another Aetna medical director wrote that Payton's policy didn't cover inpatient rehabilitation.

As time wore on, Payton went outside the company for help, writing to the state health department, the insurance department, and the attorney general's health care bureau about the "countless hours spent on the telephone by myself, family and friends, attempting to access the benefits for inpatient substance abuse treatment." In response, the attorney general's office investigated Payton's grievance and found in his favor. The investigators wrote to Aetna, saying that they couldn't understand why Payton was denied treatment and that his contract "plainly covers inpatient substance abuse rehabilitation."

Perhaps moved by the attorney general's investigation, Aetna/US Healthcare's grievance committee did finally grant Payton coverage for the treatment on August 25, seven months to the day after he first requested it. Unfortunately, on the same day, he was discovered dead in his Manhattan apartment. He is presumed to have died from an overdose about a week earlier.

slerner@villagevoice.com

 
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