FOX 29 Investigates: Family Appeals Insurance Rejection

- A local family says a wife and mother was in the midst of a battle for her health. Then her insurance company pulled coverage.

As his wife fought to get well, her husband decided he needed to fight, too, for her. FOX 29 Investigates' Jeff Cole has this report.

The Siegles of South Jersey spent the holidays without the person their lives revolve around.

"She lived, you know, to see her girls – to see her girls thrive," Ed Siegle said.

Michelle Siegle, a 49-year-old mother of two and wife of Edward, who will never forget May 31.

"I couldn't wake her up," he said. "I got her to the hospital, and they said she had a stroke. And that's how this all started."

Today, Michelle is in Philadelphia's Magee Rehabilitation Hospital, fighting to recover.

"My health is gradually increasing. It is at the point that I am getting close to my normal self," she told us.

Ed Siegle feared this day would never come. Jefferson Hospital doctors told him in June his wife might never emerge from a coma.

Cole: "They were clearly preparing you?"
Ed Siegle: "They were."
Cole: "For your wife's death?"
Ed Siegle: "I would have to make the decision to remove her from life support."

He couldn't do it.

Less than a month after her stroke, Michelle's eyes flickered open: "Our pastor and two of our friends were there, and they said she was awake," Ed Siegle said.

Stabilized, she arrived in late June at CareOne in South Jersey to begin rehab.

Ed Siegle, a systems analyst at a Pennsylvania College, was paying for her care with his employer-provided health insurance from the region's giant, Independence Blue Cross.

He says the rehab was working.

"I'd rush in from work to see her and, 'What can she do now? 'Where is she at?'" he said.

"And you'd be surprised?" Cole asked.

"I would be surprised, and I was encouraged," Siegle said.

Letters written by Michelle's doctors back his claim she was improving.

Cole: "So things were going very well?"
Ed Siegle: "Yeah."
Cole: "Until they weren't?"
Ed Siegle: "Correct."

The bad news came in mid-August. CareOne told Ed Siegle Blue Cross wanted Michelle sent home.

"The reason that they said they cut her is because, in their words, she no longer qualified for that level of care," Ed Siegle said.

He pulled $28,000 out of savings to keep his wife at CareOne.

"I had to do what I had to do, all right, I mean … This was my wife," he said.

Independence Blue Cross declined an on-camera interview and refused to answer questions on the record about the Siegle case, despite her husband's OK. It did provide statements, writing this must have been an "incredibly difficult situation for the Siegle family," adding it hopes she recovers and returns home.

Dr. Stuart Fine is a former hospital CEO and an associate professor at Temple's Fox School of Business.

"It's occurring with greater and greater frequency as people become more sensitive to the cost of providing care," Fine said.

He believes these decisions are the toughest in healthcare.

"The insurance company has legitimate concerns, as does the family," Fine said. "How many bites at the apple should a particular patient receive? … Those are dollars that now can't be spent to care for other people. It's a very, very difficult decision."

Michelle Siegle was stunned Blue Cross wanted her out at CareOne: "That was surprising because I knew that I was progressing at a small level."

Ed Siegle decided to fight. He filed an appeal and included statements from her doctors, including Jefferson neurosurgeon Pascal Jabbour, who wrote it was his opinion "that the patient continue in a Skilled Nursing Facility as it will greatly benefit her."

Siegle also challenged as "false" claims made in Blue Cross case notes that his college-bound daughter had received training and would act as her mother's "primary care giver."

Again, Blue Cross declined comment on the issue.

"There's no – no way," said Melanie Siegle, their daughter. "I have no idea why they thought that I could basically be a skilled nurse."

The Siegles won. The reviewer wrote Independence Blue Cross had "inappropriately denied coverage." Michelle Siegle was allowed to stay at CareOne.

Blue Cross argues it lost the appeal because the reviewer saw medical information it didn't have, writing, "…It showed that Mrs. Siegle had made progress, was able to participate in an aggressive rehabilitation program and approved coverage."

Now, after two denials by Blue Cross claiming she wasn't ready, she is receiving more aggressive rehab at Magee Hospital on the insurer's dime.

"I am happy," she told us. "I can't wait to be home."

Ed Siegle has prepared his home for his wife's eventual return. But he's disappointed at his insurer.

Ed Siegle: "They seem not to be concerned with the overall welfare of a patient."
Cole: "Aren't they there for that?"
Ed Siegle: "That's what I always thought."
Cole: "But you don't believe that anymore?"
Ed Siegle: "No, I don't."

Ed Siegle now expects to get his $28,000 back. He says the process started after FOX 29 began asking questions.

Blue Cross says it's a "mission-based company" which "puts its customers first."

Have a tip for the FOX 29 Investigates team? Email us at fox29.undercover@foxtv.com or like Jeff Cole's Facebook page and send us a message!


UPDATE 3/1/17:

The Siegle family tells FOX 29 Investigates they have received the second of two checks – this one worth $15,000 – from CareOne after it was reimbursed by Independence Blue Cross.

In all, the Siegles have received $28,000 back.

Michelle Siegle continues her recovery at Magee Rehabilitation Hospital. The family hopes she will be able to return home this month.

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