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THE FINE PRINT

Getting coverage for sore elbow proves a real pain

Ray Charbonneau challenged Aetna's determination that the cost for evaluating his injured leg was covered, but not the cost for evaluating his injured elbow.Jonathan Wiggs/Globe Staff

Ray Charbonneau’s health insurer recently declined to pay $450 for an evaluation he had several months ago on his aching elbow, saying it wasn’t covered.

That didn’t make sense to him because two years ago the insurer had covered a similar evaluation on his aching hamstring.

The two procedures were almost identical. Both were conducted at the same top-tier rehabilitation facility by professional therapists who put him through a battery of tests before recommending that he undergo weekslong treatment.

“Why would an evaluation be covered for a leg but not an elbow?” Charbonneau wondered. “Both were physical problems that needed help. I couldn’t see a difference.”

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So Charbonneau, 60, of Arlington, a self-employed computer repairman, took on Aetna, one of the largest health care insurers in the country with more than 20 million members and tens of billions in revenue last year. And it’s owned by CVS, one of the largest corporations in the country.

But getting Aetna to focus on his $450 problem proved futile.

After I got involved, Aetna investigated and, within a matter of hours, admitted it had wrongly denied Charbonneau’s claim and apologized.

Charbonneau’s persistence meant a savings of a relatively modest amount of money, a little more than what he and his wife pay to Aetna in monthly premiums.

But what Charbonneau did also benefits others, because it forced Aetna to make a correction that will save them from being denied coverage in the same way.

“I’m not saying there was some big, evil plot against me,” Charbonneau said after Aetna acknowledged its mistake. “It looks more like incompetence in a very large bureaucracy. Things fall through.”

Aetna has more than 45,000 employees administering a dizzying array of health care plans.

Here’s what happened:

Charbonneau, a longtime runner who has completed dozens of marathons, got treatment for his hamstring after an evaluation by a physical therapist at Spaulding Rehabilitation Hospital in 2019.

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Aetna says evaluations by physical therapists are covered and Charbonneau encountered no issues.

But when he returned two years later, the evaluation of his elbow was assigned to an occupational therapist, which at the moment seemed of little consequence to him. Charbonneau told me he was later told by Spaulding that, in general, physical therapists focus on the lower extremities (legs) while occupational therapists deal with the upper extremities (arms).

A Spaulding spokeswoman told me all physical and occupational therapists are trained in anatomy, and that there is no bright line distinction in terms of which therapists evaluate and treat arms and which treat legs. In practice, a physical therapist is more likely to treat lower extremities and an occupational therapist more likely to treat upper extremities, she said.

Occupational therapy focuses on a person’s ability to participate in daily tasks, including helping people recovering from injury to regain skills such as writing, lifting objects, caring for themselves, and supporting older adults experiencing physical and cognitive changes.

Physical therapy focuses on the person’s physical abilities to complete activities incorporating strength, balance, and gross and fine motor coordination, Spaulding said.

Evaluation of Charbonneau’s elbow was assigned to an occupational therapist who is certified as a hand therapist, the Spaulding spokeswoman said. A certified hand therapist can be either an occupational or physical therapist, she said.

For Charbonneau, it made no difference whether he was examined by a physical or an occupational therapist. The diagnosis was correct both times and he went on to be successfully treated for both his hamstring and elbow.

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The problem, unbeknownst to Charbonneau at the time, was that Aetna did not include evaluations by occupational therapists as a covered procedure, due to an oversight rather than a matter of policy.

After getting billed for the evaluation, Charbonneau called the customer service line at Aetna, which is based in Hartford. Someone promised to look into it and get back to him. Weeks passed. Nobody called.

Two more calls to Aetna followed, most recently on July 15. Again, he received assurances that his claim would be investigated. But, again, no call back.

Next, he called his wife’s employer, MITRE Corp., through which the couple is insured. Late last month, a MITRE Corp. representative, after conferring with Aetna, reported back to Charbonneau that he wasn’t covered.

The MITRE representative explained to Charbonneau in an e-mail that Aetna covered physical and occupational therapy, and physical therapy evaluations, but not occupational therapy evaluations.

“Therefore the claim is processed correctly” and Charbonneau was not covered, the MITRE representative said, based on what Aetna told her.

Once I contacted Aetna, the insurance giant quickly realized its oversight in not specifically including occupational therapy evaluations as a covered benefit.

“Upon review, it was determined that the member’s occupational therapy evaluation claim was processed incorrectly,” an Aetna spokeswoman said in an e-mail to me.

Going forward, occupational therapy evaluations will be specified as covered, the spokeswoman wrote.

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“We apologize to Mr. Charbonneau for any inconvenience this may have caused and have since reprocessed the claim,” it said, adding that Charbonneau will now be covered for his elbow evaluation.

What about the failure to return calls to Charbonneau?

“We apologize for not getting back to Mr. Charbonneau sooner,” the spokesman replied. (Actually, it hadn’t gotten back to him at all.) “A member of our customer service team did reach out to him today to let him know the claim is being reprocessed.”

Actually, Charbonneau said, nobody from Aetna at that point had contacted him by phone or e-mail.

A happy ending? Yes, I suppose, thanks to Charbonneau’s persistence. But not all of us have the stamina of a long-distance runner.


Got a problem? Send your consumer issue to sean.murphy@globe.com. Follow him on Twitter @spmurphyboston.