By On July 30th, 2014

When is a brain injury not a brain injury?


Recently a patient was referred to us for ongoing rehabilitation from an excellent acute medical rehabilitation hospital in neighboring state. He had made some recovery from his severe anoxic brain injury, but still had significant cognitive and physical deficits requiring rehabilitation in addition to having high needs for physician and nursing involvement.  As our Admissions and Case Management Team were working on the transfer and negotiating with his insurance company, the nurse at the insurance company informed us that his policy was an Affordable Care Act policy and did not offer any benefits for Acquired Brain Injury. They would provide benefits for Traumatic Brain Injury (TBI), but not Acquired Brain Injury (ABI). The highly recognized Attending Physician at his current hospital attempted to appeal this issue with the insurance company’s Medical Director only to learn that Anoxic Brain Injury was not covered by his benefits.

I found this puzzling as when a person purchases a health insurance policy does the person know what conditions are “covered” and which are “excluded” unless they read the fine print on every page. If a person’s brain is injured from any causation, don’t they need rehabilitation to help them get back to the highest level of functioning?  I thought that the Affordable Care Act was intended to make needed and appropriate medical care available to people. I am sure that the individual referred to us as well as his family didn’t realize that his Anoxic Brain Injury was not a condition which the policy’s benefits would cover. Would he have been better off if his brain injury occurred in a fall, an assault, a workplace accident or in his car?

When I was growing up, the butcher’s shop had a diagram of cow on the wall which depicted the location of each cut of meat. Are we in an era of health care reform where the butcher’s chart view of brain injury will prevail? Is it right to distinguish which type of brain injury will be covered by an insurance policy and which will be excluded?

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