Defense Department settles with Navy family over daughter’s medical claim denials

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The Defense Department has agreed to a cash settlement with a retired Navy captain and his wife after the Defense Health Agency denied their daughter's Tricare claims for physical therapy using a horse, the family said July 23, 2015. Tricare notified the Samuels family in June 2010 that their daughter Kaitlyn's use of a horse during her physical therapy sessions was not covered because it constituted unproven treatment. (Courtesy of Kaitlyn's Foundation)
From Stripes.com
The Defense Department has agreed to a cash settlement with a retired Navy captain and his wife after the Defense Health Agency denied their daughter's Tricare claims for physical therapy using a horse, the family said July 23, 2015. Tricare notified the Samuels family in June 2010 that their daughter Kaitlyn's use of a horse during her physical therapy sessions was not covered because it constituted unproven treatment. (Courtesy of Kaitlyn's Foundation)

Defense Department settles with Navy family over daughter’s medical claim denials

by: Erik Slavin | .
Stars and Stripes | .
published: July 24, 2015

YOKOSUKA NAVAL BASE, Japan — The Defense Department has agreed to a cash settlement with a retired Navy captain and his wife after the Defense Health Agency denied their daughter’s Tricare claims for physical therapy using a horse, the family said Thursday.

Jennifer and retired Capt. Mark Samuels received compensation for nearly one year of retroactively denied claims on behalf of their daughter, Kaitlyn Samuels, along with money to cover five more years of therapy, the family said.

Kaitlyn Samuels was born in 1996 with severe brain impairments that do not allow her muscles to function properly. She also has neuromuscular scoliosis, which curves her spine from side to side.

The settlement was approved June 8 and the case was formally dismissed earlier this month in Dallas, according to federal court documents.

“We are very satisfied and definitely feel like we won the battle,” Jennifer Samuels told Stars and Stripes.

Tricare notified the Samuels family in June 2010 that Kaitlyn’s use of a horse during her physical therapy sessions was not covered because it constituted “unproven treatment.”

The Samuels argued that Kaitlyn used the horse much like a dynamic balance beam, and that the doctor-prescribed therapy was the only method improving her condition.

After Tricare denied the claims, Kaitlyn tried more expensive conventional therapy that Tricare deemed acceptable. Her spine curved significantly and rapidly as a result, according to the court complaint.

“After therapy balls and benches proved useless, the family resumed using a horse as a tool and began paying out of pocket for the expenses,” the complaint stated.

A Tricare hearing officer ruled in the family’s favor upon appeal, deeming therapy in a traditional setting for Kaitlyn “a waste of government money,” according to court documents. Nevertheless, Tricare set aside the hearing officer’s findings in October 2012 and denied coverage.

The family filed a federal suit in August against DOD, the secretary of defense and the Defense Health Agency, which runs Tricare.

“Although we had a great case … we decided to settle so our litigation would not hinder political assistance with Kaitlyn’s Law,” Jennifer Samuels said.

Kaitlyn’s Law was introduced in the House of Representatives in 2013 as the Rehabilitative Therapy Parity for Military Beneficiaries Act, but the bill did not advance beyond the committee level.

The brief law would clarify that therapeutic exercises involving beams, horses and other implements are part of “rehabilitative therapy” and subject to coverage for families with appropriate military health insurance policies.

slavin.erik@stripes.com
Twitter: @eslavin_stripes

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