Ronnie Polaneczky: Health care in crisis: When luck runs out

TO THOSE who say that America needs a national health-care plan, I always answer, "We have one already. It's called luck."

Just ask Lance Lewis, who's had the good and the bad kind.

In April 1987, when Lewis, then 24, was hired by Corestates Bank as a financial analyst, he selected the most comprehensive health-care insurance from the array of plans that the now-defunct company offered its employees.

True, the plan took a bigger chomp from his paycheck than the other plans would have. But his salary wasn't great, so he wanted to know that his medical costs would be covered if disaster struck.

In November 1988, it struck in a big way. Lewis fell backward down a set of steps, broke his neck and became quadriplegic. His excellent insurance kicked in, covering every aspect of his hospitalization and rehab. Luckily, it also paid for the 24-hour nursing care he now required, so he was able to return to independent living in his own apartment.

And so it went for five years. Even though Lewis no longer worked for Corestates - he receives a small Social Security disability payment and lives off interest from modest savings - he says that the bank still considered him a "long-term-disabled employee" entitled to participate in the company's health-insurance plan.

"Corestates was self-insured, and they could decide who to let into the plan," says Lewis, now 45, who is single. He has no family to care for him, lives in a Center City apartment and always has a nurse with him.

In 1994, Corestates replaced Lewis' existing plan with an HMO that didn't offer the 24-hour nursing coverage. Willing to honor its prior obligation, Corestates agreed to craft a separate agreement to cover nursing care, Lewis says. Without it, he'd have to enter a nursing home.

The deal stayed in place for the next 15 years, as Corestates merged with Meridian and then morphed into First Fidelity, then First Union, then Wachovia. Each new entity verbally honored the past agreement with Lewis. Each year, at open-enrollment time, Lewis would re-up, then get back to life.

By last fall, Wells Fargo had absorbed Wachovia. Lewis filled out his forms, as usual, then spoke with the company's human-resources people to confirm the nursing deal.

"What nursing deal?" they basically asked him. "We don't know anything about that."

While Lewis would still be eligible for medical coverage through Wells Fargo - Aetna administers the company's plan - Wells Fargo said that it could find no documentation that the separate nursing agreement ever existed (Lewis himself long ago lost track of his copy).

So they were cutting off Lewis' nursing. His medical coverage would continue, but the nursing care would end by April 1.

"If the insurance covers medicine that I can't even take, because I can't open a pill bottle, what good does the insurance do me?" asks Lewis.

His luck had run out.

To call Lewis' case wild is putting it mildly. I spoke with several human-resources types who were startled that he expected to have any sort of relationship with Wells Fargo, given that he hadn't worked for Corestates for over two decades.

"It sounds like he was very lucky for a long time," said one expert, who was unfamiliar with Lewis' case but didn't want to be identified for fear of seeming uncaring about his plight. "Most people in his position would probably wind up in a nursing home."

That's what worries Lewis.

"I need constant monitoring," says Lewis, a big, friendly guy who can feel nothing below mid-chest. "I can't eat, drink or take medicine without help. I even need nurses to perform my bodily functions."

He's catheterized at least three times a day, and nurses must "dis-impact" his bowels since he hasn't the ability to move them on his own. Since he's prone to bedsores - one of which required surgery to close - his weakened skin needs constant vigilance from skilled nurses to avoid more breakdown.

He's also prone to a syndrome called autonomic dysreflexia, during which his blood pressure spikes so high he's at risk for a stroke. Because his nurses have been with him for so long, they can spot the syndrome's symptoms quickly enough to avert a life-threatening situation.

"In a nursing home, I'll be one of 12 patients that an aide is taking care of," he says. "I'm terrified of what would happen."

Wells Fargo spokeswoman Barbara Nate told me that the company "clearly would honor an existing obligation of a predecessor company," but that no documentation exists to prove the obligation existed.

Well, maybe so. But someone has been paying the up-to-$300,000 per year it costs for Bayada Nurses to provide in-home care to Lewis. Currently, Aetna, Wells Fargo's health insurer, is paying those bills, according to a Bayada spokesman.

Someone had to give that order, whether it's on a printed document or not.

"After that original agreement [in 1994], it doesn't appear as if anyone wrote anything down," says Lewis' attorney, Jeff Goldman. "That doesn't mean the agreement wasn't in place."

By last week, after calls from the Daily News, intervention from U.S. Sen. Arlen Specter, D-Pa., and repeated hounding by Goldman, Wells Fargo finally agreed to give Lewis 180 days to appeal its denial of his nursing care.

That will give him time to figure out what his next move should be. And it will give the rest of us a chance to ponder a timely question, given the health-care debate raging in Washington.

When we buy insurance - especially the Cadillac kind, like Lewis bought - aren't we buying a hedge against disastrous luck, the kind that Lewis suffered when he fell backward down those steps? The kind that will never be reversed, the way his quadriplegia will never be reversed?

If you're someone like Lewis, where is the fairness of the deal, when an insurer can decide when your luck has run out, simply by changing the terms of the policy at renewal time?

E-mail polaner@phillynews.com or call 215-854-2217. For recent columns:

http://go.philly.com/polaneczky.

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http://go.philly.com/ronnieblog.