How one family and their prosthetist dealt with an insurmountable health insurance cap.
Mike Garone was running on his Otto Bock C-Leg less than two weeks after first testing it out. It was comfortable. Garone says he felt like he could go anywhere and do anything.
But the prosthesis did not come without obstacles.
Because of the wording in the Garone family’s insurance contract, they wouldn’t have been able to afford the high-tech device for their 17-year-old whirlwind of energy.
“They had prosthetic coverage, but the contract they had was very specific in that it did not cover microprocessor-controlled prosthetics,” says Erik Tompkins, CP, BOCPO, of M&M Prosthetic Associates, Poughkeepsie, New York. “We knew right away that he wasn’t getting a computerized C-Leg unless [the Garones] were paying for it.”
The Garone’s insurance offered a 50-50 co-pay with a lifetime maximum of $25,000 for durable medical equipment (DME).
“That doesn’t even cover one leg,” Garone’s mother Cathy says of the insurance cap. “It was something we couldn’t afford without help.”
Through a friend of a friend, Garone’s story found its way to Nick Toholckec ears. In his 70s and suffering from diabetes-related health issues, Toholckec did not use his C-Leg any longer and was moved by Garone’s story. He wanted to donate his prosthesis to the 17-year-old.
When Toholckec contacted Tompkins, the Garone family was overjoyed with the donation. But since the insurance company had already denied the C-Leg, Tompkins was concerned about whether such a donation would be possible. He knew he would need to work through the insurance company’s “red tape.”
“When the family approached me, I said I would do the best I could but that I would have to take care of some legal issues first,” Tompkins says.
It turned out to be a fairly easy process. Tompkins was referred to an attorney who advised him to contact the Garone’s insurance company.
“The insurance company was helpful, and they understood what I was about to do. As long as I wasn’t billing the insurance company twice for the device, they were fine with it,” Tompkins says.
Prostheses that are no longer used are usually donated to charitable and other organizations that either ship them to countries around the world that have great need, or disassemble them and re-sell the parts. Oftentimes, however, unused devices sit in a closet or on a shelf in the owner’s home gathering dust.
For the Garone family, securing the donation meant much more than providing a mobility device.
“It’s almost like it gave Michael his life back,” Cathy Garone says of the C-Leg. “I wish the laws would change where everyone would be entitled to them.”
In an unfortunate turn, Garone slipped off a dock and into a lake while wearing the C-Leg in late July. The device turned out to be unsalvageable, and the family is trying to organize a fundraiser with hopes of getting a new one.
“It could be something like a pylon, which would be about $1,000, or it could be the whole knee,” Tompkins says.
Brady Delander is a freelance writer based in Denver, Colorado.
To read more about Mike Garone, see “Mike Garone: Standing Up to Every Challenge“.