Legal Question in Health Care Law in California

Forced into nursing home

Can a health insurance company deny a long term care patient his right to have home health care instead of having to go to a nursing home. He is mentally competent, currently has the homecare and is with his family. Is there a case law out there that states putting a sane person against their will into a nursing home is detrimental to their health. He has advance parkinson's and is confined to bed and wheelchair. His wife is fighting the insurance company to keep her husband at home with the current care.I need to find a legal leg for them to stand on. The insurance company says it is too expensive to continue the home care. No consideration given to what is best for the patient. thank you


Asked on 10/16/04, 2:07 am

1 Answer from Attorneys
FAHED SAYEGH SAYEGH & ASSOCIATES

Re: Forced into nursing home

Under MediCare guidelines, which are typically the guidelines utilized by most health plans, to qualify for home health, a patient must demonstrate that he/she is homebound, and that there is a skilled need. Of course, both requirements are fact-intensive. Thus, based on the inquiry, it is difficult to provide a definitive response. In any respect, if you can show that there is medical necessity (or skilled needs) (i.e., decubitus ulcers, rehabilitation, blood draws, etc.), the health plans will likely not have much leg to stand on. You should document everything, save all letters, and exhaust all appeals/grievance procedures provided by the health plan.

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Answered on 10/18/04, 8:24 pm


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