After repeated denials, insurance company approves boy’s $6,000 wheelchair

Anchor/Reporter

GOFFSTOWN, N.H. —

A New Hampshire family already facing a devastating diagnosis for their son says they also had to fight their insurance company to get him a wheelchair his doctor said he needed.

Theirs is a familiar story for the increasing number of Americans who say they have struggled to get health insurance to cover necessary treatment or equipment.

Derek and Kara Hamilton say they first noticed changes in their son Owen about two years ago, when he began using his arms to pull himself up the stairs. A visit to a physical therapist a few months later led to a life-changing diagnosis: Duchenne muscular dystrophy, a rare genetic disorder that causes progressive muscle weakness.

Since then, the Hamiltons say Owen’s condition has made it increasingly difficult for him to walk. While the 8-year-old can still take some steps on his own, his parents say he cannot walk long distances and struggles to make it through a full school day.

“We went trick-or-treating last fall, and he could not walk with his friends,” Kara Hamilton said. “He had to be put in a wagon to finish.”

Owen’s doctors recommended an ultra-lightweight wheelchair, which his parents say would allow him to move more independently and help preserve his mobility for as long as possible. But the family says the insurance provider, Blue Cross Blue Shield of Minnesota, repeatedly denied coverage for the roughly $6,000 chair, even after multiple appeals.

According to the insurer’s denial, the wheelchair was considered “not medically necessary” because Owen still has some ability to walk. The company’s wheelchair policy required Owen to need the chair full-time before it would approve coverage for the expensive ultra-lightweight model, which the family said is necessary because of his small size.

“So because he can walk today, their answer is no,” Derek Hamilton said. “My mind was blown. I don’t know how you can look at a child with a rare genetic disease and not think that he needs this medical equipment.”

Without the approval, the Hamiltons have been borrowing a wheelchair. They’re not able to afford to pay the cost to purchase one out of pocket.

“It will prolong him walking for longer and being more mobile,” Kara Hamilton said. “It’s super important to me. We just want him to live a normal childhood as best he can.”

Owen’s doctor, Julia Shah at Boston Children’s Hospital, argued in support of the request, writing that the wheelchair was medically necessary and warning that without it, Owen faced a higher risk of falls that could further limit his movement.

“The requested wheelchair is not for convenience,” Shah wrote. “It is required because Owen cannot safely and consistently meet his daily mobility needs.”

The Hamiltons say their experience reflects the frustration many families feel when dealing with health insurers.

“Why do we have to fight tooth and nail for just the basic medical care that he needs?” Kara Hamilton said. “It seems like it’s a fight with every type of treatment we have done.”

“I’m learning day by day every time we have to fight for something that their expectation is that people would just quit and go away,” Derek Hamilton said.

After sister station WCVB began asking questions about Owen’s case, Blue Cross Blue Shield reversed its decision and approved the wheelchair. Because of privacy laws, the company said only that the approval came after additional information was provided by Owen’s doctor.