A Navy Captain's Increasingly Absurd Fight Against Military Insurer to Pay For Disabled Daughter's Physical Therapy
When Kaitlyn Samuels was 4 months old, her parents, Mark and Jennifer, worried that she couldn't reach for her toys. Doctors initially assured them that it was probably normal, but after two months brought little improvement they ordered a battery of neurological tests that revealed Kaitlyn had a very rare and very serious brain malfunction.
The years since then have been a struggle, as Kaitlyn has suffered the effects of epilepsy, cerebral palsy and all sorts of related complications. She can't speak or walk by herself. Her food has to be blended into liquid form because she can't chew. Her brain is frozen in perpetual toddlerhood.
Kaitlyn also suffers from severe scoliosis. Left unchecked, the condition would get progressively worse, with the increasing curvature of the spine diminishing lung capacity, popping joints out of socket and eventually killing her by crushing her internal organs. It can be treated with physical therapy, but traditional methods didn't work for Kaitlyn; she would grow bored and shut down, rendering the session worthless.
In 2009, the Samuels found a solution at Rocky Top Therapy Services in Keller, where the family was living. There, Kaitlyn is placed on a horse that is then led in a circle by volunteers and Suzanne Sessums, the family's physical therapist. The horse's breadth stretches Kaitlyn's legs while its movement works her hips and pelvis. All the while, she has to keep herself upright, strengthening her back and neck muscles. More important, Kaitlyn enjoyed being on the horse and stayed engaged for the duration of the twice-weekly, 30-minute sessions.
Mark Samuels is a captain in the Navy, and the treatments were paid for through TRICARE, the health plan for Department of Defense employees -- at least they were for nearly a year, until TRICARE abruptly decided the treatments count as hippotherapy and would not be covered under the Samuels' health plan.
What's ensued for the Samuels has been a two-year battle against a Kafkaesque bureaucracy. When it determined Kaitlyn's therapy wasn't covered, TRICARE decided the Samuels should repay the insurer $1,300 for several month's of treatment they hadn't previously objected to. The Samuels filed an appeal, claiming their daughter was simply receiving physical therapy that happened to be on a horse, and that the treatments should be covered.
The appeal wound its way through the byzantine Department of Defense appeals process -- at one point in the fall of 2011, hearings were delayed for two months because Congress had not passed a federal budget -- before the family wound up in a Dallas courtroom to argue their case.
At the hearing, which we covered, both sides argued over the definition of hippotherapy. Sessums, who has been a therapist for 13 years, argued that the horse is merely used as a tool for physical therapy, the same way a bench or exercise ball are often used. "I am a physical therapist, not a hippotherapist," she explained, and her experience working at nursing homes, the Fort Worth Independent School District and elsewhere would to seem to bolster that claim.
TRICARE's argument in response was elegantly simple, if based on a basic logical fallacy: Kaitlyn's treatment uses a horse; that any therapy using a horse is, by definition, hippotherapy; and that hippotherapy is not covered by TRICARE. What's more, approving Kaitlyn's treatment could lead the insurer down a slippery slope. "Could Sea World hire a physical therapist [and charge TRICARE]?" its attorney asked.
Claude R. Heiny, the administrative judge in the case, sided definitively with the Samuels. Just because physical therapy takes place on a horse doesn't mean it's not physical therapy, he determined.
"It is more beneficial to use the horse as a tool, because [Kaitlyn] engages in her physical therapy on the horse and fails to cooperate with her treatment in a clinical setting," he wrote. "It cannot be forgotten that even though [Kaitlyn] is 15 years old, she has the mental capacity of a toddler-preschool child. It would be a waste of the Government's money to pay for therapy in a traditional setting for it would provide no benefit."
He issued his ruling on March 30, but the Samuels didn't learn of it until last week, when they received a notice from TRICARE.
"After due consideration of the appeal record, I reject the Recommended Decision of the Hearing officer," wrote Michael O'Bar, the insurer's deputy chief. Because even though DoD's own judge determined otherwise after a monthslong appeals process, TRICARE still considers Kaitlyn's treatment as hippotherapy and refuses to pay. That whole appeals process was nonbinding.
To add one additional layer of absurdity, it should be noted here that Kaitlyn's horse-based treatment is way cheaper than traditional physical therapy since the animals and volunteers at Rocky Top donate their time, and Sessums charged only $80 per 30 minute session, compared with the typical $300 rate.
The Samuels are understandably at their wit's end. Kaitlyn is continuing her treatment at Rocky Top with grant money the treatment center has received, but that will eventually run out, and they remain convinced TRICARE should cover the costs. They're considering a lawsuit, and Mark plans to contact Senator John Cornyn's office. Until then, they're hoping people will sign their Change.org petition urging TRICARE to accept the decision of the administrative judge.