Kaiser pays for lighter wheelchair

Pat Oliva has paraplegia and uses a wheelchair. After much rehabilitation, he could once again drive and get out into the community. But his wheelchair would not fit into his car. When he went to pick up his kids from school, he had to leave his wheelchair in the driveway at home.

Needed a lighter chair

Oliva asked Kaiser, his health benefit plan, to pay for a lighter wheelchair. His wheelchair assessment had been done more than a year ago - before he got out of the hospital. Kaiser denied his request, in the erroneous belief that the wheelchair he wanted was heavier than the one they offered. So Oliva called PAI.

PAI researches plan benefits

In talking to Oliva, Aleyda Toruno, an advocate in PAI's San Diego office, learned that he has limited mobility and limited strength in his upper body. She asked him to get his Evidence of Coverage - the benefit summary from the contract between his employer and the health plan. It outlines what items and services the plan covers, and the standard for approving services and equipment.

Medical necessity is key

Under the Kaiser plan, Oliva needed to show medical necessity. Toruno talked to his doctor, who wrote a letter explaining what Oliva needed - a lighter wheelchair because of a shoulder injury caused by repetitive use. Toruno then helped Oliva gather information about each wheelchair to give to his doctor and to use in filing a grievance.

Evidence packet nets money for chair

Because he needed it so badly, Oliva went ahead and bought the wheelchair. Kaiser reimbursed him for the wheelchair after he sent in the evidence packet he and Toruno had put together.

"Aleyda is good," says Oliva. "I really appreciate what she did. That old heavy wheelchair was hurting my back."