Woman's life saving procedure denied by insurance

November 15, 2011 8:14:52 PM PST
A mother is making a desperate effort to save her daughter who has a rare disease.

Doctors say the seriously ill 25-year-old needs a special procedure, but the insurance company claims it's not medically necessary.

"I love basically my family, my cat," Jackie Emmanuel said.

25-year-old Jackie Emmanuel has a disease called autoimmune encelophathy, where her body literally attacks her brain.

"She is definitely starting to deteriorate now," said Janice Emmanuel, Jackie's mother.

Janice Emmanuel is watching her daughter get more mentally unstable by the day, and now she needs a home health aide.

It's a frightening sense of déjà vu as Janice has seen it all before.

"She was absolutely psychotic. One therapist that was working with her said that she had over 200 voices in her head," Janice Emmanuel said.

Three separate times Janice's insurance company paid for a hospital procedure called Plasmapheresis, which turned Jackie's life around.

"She was completely functioning. She stared volunteering," Janice Emmanuel said.

"This is the soup kitchen. It's where people come when they're hungry," Jackie Emmanuel said.

But last spring, Jackie started becoming increasingly psychotic again.

"The voices came back. The voices were back, really, really loud," Jackie Emmanuel said.

Janice was stunned when her same insurance company, United Health Care, this time, denied the Plasmapheresis treatment.

She appealed and included letters from four separate doctors, saying it's the only treatment that works.

Psychiatrist Phyllis Edelheit is one of those doctors.

"It's critical for her to have this treatment, without this treatment she will die," said Dr. Phyllis Edelheit, a psychiatrist.

"I basically think they're saying we've spent a lot of money on your daughter and we don't want to spend anymore on her," Janice Emmanuel said, "They're basically saying she can die now, because we're not going to take care of her."

"You see this as an insurance death panel," Eyewitness News reporter Sarah Wallace said.

"Absolutely, because the end product of this is that my daughter will go completely insane," Janice Emmanuel said.

United Health Care told Eyewitness News: "Clinical guidelines on this treatment have changed over the years. Two independent external reviews in accordance of State Law agreed with our decision not to recommend this treatment. We are bound by the State's decision."

"They should have looked at this as a rare disease," said Mark Scherzer, attorney.

Attorney Mark Scherzer specializes in insurance cases.

He reviewed Jackie Emmanuel's file and thinks the insurance company and the state review were wrong.

"You know the insurance company is basically a death panel here. I mean she's going to die if she doesn't get this treatment," Scherzer said, "Yeah, and I think it's imperative that this be followed up so that she does get the treatment."

"It's not frustrating, it's devastating," Janice Emmanuel said, "I need to help her and I can't help her."

Eyewitness News has now put the Emmanuel family in touch with an advocacy group called Community Health Advocates.

They are now helping and will ask the insurance company to re-consider the case using a different classification.

It's Jackie's last hope.


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