A Guide to Your Rights
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An Overview and Introduction
We all try to prepare to meet life’s challenges. No one can be fully prepared, however, for the effects of a catastrophic injury. Such injuries change forever not only the lives of the victims themselves, but also the lives of family members, friends, and often other support providers.
We live in a world where amazing medical skill and technology, and sophisticated rehabilitation resources are available for victims of trauma and other catastrophic events. All too often, however, a maze of government agencies and health insurance bureaucracies pose significant barriers that make it difficult for victims and their families to take full advantage of the available treatment and rehabilitation options. These administrative and logistical burdens can impose an enormous strain on families already overwhelmed by a life-changing tragedy. And sometimes, these burdens effectively prevent victims and their families from getting the best medical care and rehabilitation care possible.
We are trial lawyers, and our clients are frequently individuals and families who have suffered catastrophic injuries. Over decades, we have watched first-hand as families, in the face of unexpected and sometimes overwhelming adversity, adjust and reconfigure every aspect of their lives. We thought it would be helpful to gather, in one place, some of what we have learned about the kinds and categories of resources that are available to families and individuals as they move forward.
Health Insurance
Until recent years, the overwhelming majority of Americans received health insurance through their jobs. Those numbers have declined somewhat in recent years, but employer-sponsored health insurance remains the most common source of health insurance.
Whatever the source, health insurance is almost always the primary source of funding for health care and rehabilitation services after a serious injury. Health insurance comes in many, many different forms. A Health Maintenance Organization, or “HMO,” often includes a gatekeeper physician who must approve all specialty referrals and consultations. Another common arrangement, known as a “Preferred Provider Organization,” does not require a gatekeeper to pre-approve specialist referrals, but does impose additional costs (such as a larger co-payment) if the specialist is outside the preferred provider network. Under traditional “indemnity” plans, the health insurer pays 80% of the costs of medical care, and the patient pays 20%.
Whatever the precise configuration of health insurance, one universal feature is the presence of some form of “utilization review”. Insurance companies have review mechanisms that allow them to influence, and in some cases participate in, decisions that affect which health care and rehabilitation services get reimbursed and which ones don’t. All too often, a decision to deny reimbursement is in practical effect a decision to deny the patient the care. Sometimes these insurance decisions are not consistent with the medical recommendations of the doctors and therapists who are working with the patient and who know the patient best. All too often, it falls to family members and loved ones to ensure that the family member receives the medical care and rehabilitation services needed to give the patient the best chance at the maximum recovery possible.
When a health insurer approves or refuses approval for medical care in advance of the medical care being provided, the process of insurer review is called “prospective utilization review”. Prospective utilization review is present to some extent in virtually every form of health insurance available today, even forms of health insurance not typically seen as “managed” care, such as PPO’s and traditional indemnity plans. Health insurer review that occurs after the fact is often called retrospective utilization review. top
Insurance companies sometimes participate indirectly in decisions that affect health care and rehabilitation, through the use of direct and indirect incentives in the insurers’ financial arrangements with healthcare providers. These financial arrangements are set up in an effort to control the costs of health insurance, and most of the time do not have any adverse effect at all on patient care. Sometimes, however, these incentives and financial arrangements can potentially play a role in medical decisionmaking.
In the face of catastrophic injuries – and the enormously expensive medical care that follows a catastrophic injury – it is helpful to bear in mind that patients and their families, and their healthcare providers, are looking out for the patient in ways that no outside insurance company possibly can. Sometimes, providers and families do not see eye to eye with managed care health insurers, regarding what medical care a patient needs and what medical care is and should be covered under the insurance policy. These disagreements can take many different forms: the insurer may question and refuse to pay for care on the ground that it is not covered. They may seek to limit the cost or duration of care, or even question the reasonableness and necessity of medical care recommended by treating clinicians. Whatever form this managed care interference takes, it is important that the family and medical care providers fully understand what the patient’s rights are, under the insurance policy itself and also under the laws of Pennsylvania. Sometimes, it takes a strong stand to ensure that a patient receives the medical care he or she is entitled to.
Before turning to specific tips for dealing with health insurers, it is worth stressing that the most important point, by far, is communication with doctors, nurses, and therapists. Talk to them. Know what they are doing for you or your loved one, and know what they think will help. Find out what they think, what the prospects are, what the treatment options are, and what treatment settings are appropriate and will be appropriate in the future. If you don’t think you know what is going on, ask the healthcare providers for some time. If you are in a hospital or other institutional setting, a social worker will often be able to set up a meeting to discuss treatments and treatment options. A solid and informed relationship with healthcare providers is the single most important step you can take to ensure that you or your loved one get the best care possible. top
In addition, there are some other straightforward things that you can and should do if there is any prospect at all that a dispute might arise with the health insurer.
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Obtain a copy of the insurance contract that establishes and governs the available benefits (sometimes this is a document that is referred to as a “plan document”). Although often quite dense and difficult to read, these documents create legal rights and obligations for the patient and for the health insurer. Health insurance companies are required by law to provide these documents.
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Know and understand the nature of the injuries, the treatment being recommended and its alternatives, and the reasons for the recommended treatment. Letters from physicians to the healthcare coverage provider outlining these issues are always helpful in the event of dispute, and may be necessary.
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Be persistent. If a health insurer disagrees with what a treating doctor, nurse, or therapist says (or what you understand the health insurance policy to require), do not take the first “no” as an answer. When dealing with a claims person or adjuster, do not be afraid to ask to speak to a supervisor.
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Keep records of your managed care contacts. Record, in one notebook, all communications with the health insurer. You should write down the date and time of all communications, the name and title of the people you speak with, and a brief summary of the conversation. (It is important that you use a single notebook or notepad so that you have all these notes in an easily accessible place.) If you have to leave a message for someone, record that in the notebook too.
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If a managed care representative tells you that they will get back to you, ask them when they will do so. Ask if there is some way that you can get back in touch with them, in the event that they do not follow up with you as promised.
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Whenever you write to an insurer, keep a copy of what you send and make a note of when you sent it and how. If you can, it’s a good idea to send things by both first class mail and certified mail, return receipt requested (the first class mail will get there sooner, and certified mail will result in a receipt that confirms delivery in the event the materials get lost).
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Most healthcare insurers have a variety of internal processes that purport to evaluate the medical necessity of care and determine the care for which they will pay. Pre-certification, peer review and similar processes may result in denial or limitation of coverage, significantly affecting a patient’s medical care. These decisions are not final and are subject to formal and informal challenge. These decisions can be arbitrary, unfair and wrong. Improper conduct in these processes can be the basis for litigation on behalf of the patient.
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Be aware of the healthcare coverage provider’s claims and appeals procedures. Many insurance policies and employee benefit plans set forth specific processes that must be followed to file and pursue a claim and to appeal any adverse determination. Often, there are strict time deadlines within which action must be taken. For example, it might be necessary to file a complaint or a grievance within a specific number of days after a decision. Ask about these deadlines, and ask the insurer to send you information in writing that tells you what the appeal procedures are and how you can follow them. Failure to know and follow these procedures can result in forfeiting rights the patient might otherwise have. top
The complicated administrative processes established by many managed care providers can be daunting for even the most motivated and focused family members. This is especially true when a family is still dealing with the burdens of a catastrophic injury. Obtaining and utilizing the services of an advocate, whether formal or informal, whether legally trained or otherwise, can sometimes mean the difference between receiving quality care in a timely fashion, and unnecessary delays and denials that can effectively deny a patient the best chance at recovery. Often, case managers in a hospital or rehabilitation facility are extremely effective advocates for patients, doctors, and therapists. In some situations, however, the assistance of an attorney may be necessary.
The Pennsylvania Attorney General has a healthcare unit that can be a helpful resource for patients, their families and their advocates. In certain circumstances, the Attorney General may investigate or take action on behalf of consumers. This unit can be contacted at:
Office of the Attorney General
Health Care Unit
14th Floor
Strawberry Square
Harrisburg, PA 17120
(717) 705-6938
http://www.attorneygeneral.gov/ppd/health/index.cfm
You should be aware, however, that the Attorney General’s powers in this area are sometimes limited. When you contact the Healthcare Unit, you should discuss at the outset whether or not your particular situation is one where the Attorney General is likely to be able to help.
There are also private companies that assist insureds, and act as their advocates, during the managed care appeal process.
There is a firm headquartered in Philadelphia, Healthcare Advocates, with a national reputation in this area. http://www.healthcareadvocates.com.
There are also attorneys who specialize in managed care issues.
If a catastrophic injury leaves the family breadwinner out of work, families often need private health insurance to continue after an accident. Under a federal law known as the Comprehensive Omnibus Budget Reconciliation Act of 1986 (“COBRA”), eligible employees can continue to purchase their health insurance benefits from their employers for a period of up to 18 months after employment has ended. Normally an individual must affirmatively elect to receive this coverage within 30 days after receiving notice from the employer that they are eligible for this continued coverage. Changing health care plans after an accident can sometimes result in a gap in coverage for pre-existing conditions, and this can make COBRA coverage even more important.
Patient Safety
Medical mistakes are one of the leading preventable causes of death in this country. A 1999 report by the Institute of Medicine estimates that as many as 44,000 to 98,000 people die in U.S. hospitals each year as the result of lapses in patient safety. There are many sources of information that contain information about steps that patients and their families can take to minimize the chances of patient mistakes. A good place to start is a fact sheet developed by the United States Department of Health and Human Services, in partnership with the American Hospital Association and the American Medical Association, which is available at http://www.ahcpr.gov/consumer/5steps.htm
There is also a fact sheet specifically applicable to children and this can be found at http://www.ahcpr.gov/consumer/20tipkid.htm.
Another excellent resource is http://scilib.ucsd.edu/bml/safety.htm.
If a medical error does occur, the Commonwealth of Pennsylvania has a state agency, known as the Patient Safety Authority, that is charged with identifying problems and recommending solutions that promote patient safety in health care facilities. Under Pennsylvania law, medical facilities are required to notify both the Patient Safety Authority and patients or their families of events that result in death or compromise patient safety, and that result in unanticipated injury to the patient requiring the delivery of additional health care services. Pennsylvania law also requires facilities to report “near misses” – mistakes that pose a risk of injury but do not cause an injury or require additional medical care. Near misses, however, do not need to be reported to patients or their families.
This Patient Safety Authority can be contacted at:
Pennsylvania Patient Safety Authority
P.O. Box 8410
Harrisburg, PA 17105-8410
(717) 346-0469 (phone) (717) 346-1090 (fax)
The Patient Safety Authority primarily works through reports that come from health care facilities. Patients and consumers can also directly report complaints to state regulatory authorities. Complaints related to hospitals and ambulatory surgical facilities can be directed to the Pennsylvania Department of Health: http://www.dsf.health.state.pa.us/health/site/. Complaints against individual licensed medical professionals can be filed with the Department of State’s Bureau of Professional and Occupational Affairs: http://www.dos.state.pa.us/bpoa/site/default.asp.
Private Benefits: Motor Vehicle Insurance
If someone is injured in a motor vehicle accident, motor vehicle insurance is another potential source of medical coverage. This coverage is potentially available even if the injured person was not a driver or a passenger in the car, so long as the accident arose out of the maintenance or use of a motor vehicle.
In Pennsylvania, the law requires that every policy of automobile insurance include medical benefits of at least $5,000. In our experience, most people purchase automobile insurance policies that provide medical coverage that is either at that low level, or very close to it. The amount of medical benefits available under an automobile policy can often be spent – or “exhausted” – with a single day in the hospital. Nevertheless, this is a source of coverage that should not be overlooked.
These benefits can be subject to many of the same types of claim “roadblocks” found with private medical insurance. However, because the extent of first-party coverage is often limited, in the event of catastrophic injuries these types of problems do not come into play.
Motor vehicle insurers are also required by law to offer coverage for “income loss benefits” to replace income lost as a result of an accident. They are required to offer accidental death benefits and funeral benefits, and “extraordinay medical benefits” coverage which covers medical expenses in excess of $100,000. You should check insurance policies to see whether any of these coverages are available.
Private Benefits: Disability Insurance
While a catastrophic injury may bring the life of a family to a halt, it does not stop the business of mortgage companies and utility companies, and does not stop the need for food and other necessities of life. Disability insurance can help fill this gap.
This section discusses private disability insurance, which many people have through work. Public disability benefits are potentially available from the federal government through Social Security programs, and potentially through other sources as well. These public disability resources are discussed below.
In general, there are two different types of private disability insurance: short-term disability and long-term disability. Short-term disability insurance generally begins at the time an individual becomes disabled and, as its name suggests, does not last very long (for example, a typical short-term disability policy may provide coverage for ninety days or six months). Long-term disability coverage generally does not begin until after an individual has been disabled for a certain period of time. Usually, long-term disability picks up when short-term disability terminates. For example, a 90-day short-term disability policy would be paired with a long-term disability policy that would begin to provide benefits after 90 days.
This insurance can be of critical importance. It is important that short-term disability benefits be pursued as early as possible. Most insurance policies have procedures in place that set up deadlines and timing requirements that are important to attempt to meet. If your employer sponsored or purchased the policy, human resources personnel at work can often help handle the paperwork necessary to apply for disability (although it is important that you stay involved in the application process and make sure that the necessary paperwork is being taken care of).
Often medical review is required to establish eligibility for benefits, and it is important that the disability insurer be provided the medical records and reports that document the extent of the victim’s injuries and disabilities. Even if an employer’s human resources department is helping with the paperwork, much of the burden of gathering this medical information from doctors and therapists often falls on victims and their families. This is a chore that needs to be taken care of, because disability carriers often claim that they are only required to consider the documents and information placed in front of them, and disability carriers might be less than diligent in their own efforts to gather medical records and information.
If a disagreement arises between the insured and the insurance company about whether or not an individual is disabled, it is important to get a copy of the disability policy (sometimes this is a document referred to as a “plan document”), and to review carefully the policy’s definition of “disability”, as this term can vary from policy to policy.
Most disability policies guarantee an income level that is a certain percentage of pre-disability income, and many long-term disability policies provide that the private disability benefits will be reduced by the amount of Social Security benefits that are received (Social Security benefits are discussed below). Because social security benefits can reduce the disability insurer’s obligations, many policies cover the cost of representation during the social security application process. Normally, if an award of social security benefits includes a retroactive award for previous time periods that were also covered by disability insurance, the insured is required to reimburse the insurer for all or part of these retroactive benefits.
Some short-term disability policies may also require the insured to reimburse the disability carrier for amounts received from social security. Many do not. It is important to review the language of the particular policy at issue.
Private Benefits: Workers Compensation
In Pennsylvania, as in most states, employers must provide workers compensation for work-related injuries sustained by their employees. Workers compensation provides benefits for medical expenses as well as for wage loss (sometimes called indemnity). These benefits are available for work-related injuries regardless of fault – in other words, they are available even if an employer claims that the injury was a result of the ’s, or another worker’s, negligence.
Most employers provide these benefits through the purchase of workers compensation insurance. Employers are required by law to provide these benefits, and workers compensation will almost always be a primary source of medical and wage loss benefits in a work-related injury.
In Pennsylvania, workers compensation pays for reasonable and necessary medical care, and the workers compensation carrier essentially retains control over the medical care provided for the first 90 days after injury. Under many circumstances, an employee is limited to receiving treatment from certain enumerated physicians and, as with many types of “managed care” scenarios, this puts a significant amount of control over the injured worker’s medical care in the hands of the workers compensation carrier.
The availability and extent of workers compensation benefits is governed by statute. There is an extensive and complicated body of law governing the procedural and substantive legal rights of injured workers and their employers/insurance carriers. There is a state agency in Pennsylvania whose sole purpose is to resolve disputes that arise between an injured worker and his employer/insurance carrier. The injured worker’s legal rights are seriously circumscribed by statute and case law decisions. Often an attorney advocate is necessary to protect the injured worker’s rights.
You should check insurance policies to see whether any of these coverages are available.
Public Benefits:
Commonwealth Of Pennsylvania
Medical Assistance/Medicaid is available to disabled individuals living at the poverty level through the Pennsylvania Department of Welfare. Usually, a hospital or rehabilitation facility will have personnel available to help negotiate the many procedural steps necessary to put this coverage in place.
Medicaid health insurance coverage for disabled adults is subject to income eligibility. In order to be entitled to Medicaid, an injured person must be “disabled,” have a very limited income (less than $739 per month) and very limited resources (less than $2,000 in assets). These eligibility requirements are somewhat different for individuals living with dependent children. Furthermore, workers who have disabilities but are still able to work in a limited capacity, and who are receiving social security benefits, may be able to receive health insurance through the Medical Assistance program, if their assets and income fall below federal poverty levels.
Health insurance for children is available through two different sources.
The most common source of insurance coverage for children is through the Childrens Health Insurance Program (“CHIP”). Generally, a family must earn enough that the family is ineligible for medical assistance, but still have a limited income. The income limits vary with family size and the age of the children, and are adjusted from time to time. As of the spring of 2005, a family of 4 could earn up to $38,700 and qualify for free insurance, and could earn up to $45,473 and qualify for subsidized insurance. Pennsylvania Children’s Health Insurance Program can be contacted at (800) 986-KIDS. Additional information, and an on-line application, is available through the Pennsylvania Insurance Department’s website: www.ins.state.pa.us.
State-funded health insurance for disabled children may also be available through the Department of Public Welfare. This coverage applies only to the disabled child and not to other, non-disabled family members. The coverage is available no matter what the parents earn. Personnel at a hospital or rehabilitation facility should be able to help you understand, and work through, the specific requirements for this program.
Medical Assistance through the Commonwealth of Pennsylvania Department of Public Welfare is often provided through private managed care insurance companies. Furthermore, the Department of Public Welfare has its own mechanisms for monitoring and controlling medical care costs. Patients who have insurance through DPW can face many of the same problems with an insurance bureaucracy (such as disagreements about what is medically necessary) that privately insured patients sometimes face. It can raise many of the same problems for seriously and catastrophically injured patients that privately insured patients face.
The Department of Public Welfare also provides a variety of other benefits that may be essential to keep a family on its feet. These include food stamps, energy assistance, and in some instances cash assistance. Because of the tremendous impact a catastrophic injury has on the ability of a patient to survive economically in our society, these may be invaluable, particularly for patients with limited financial means before their injury. Information concerning DPW benefits, eligibility, the application process and the location of local DPW offices can be found at DPW’s website, www.dpw.state.pa.ustop
Public Benefits:
Crime Victims Compensation Fund
An individual injured by a violent crime may be eligible to receive up to $35,000 from the Crime Victims’ Compensation Fund. Examples of violent crimes include not only robberies and assaults, but also child abuse and drunk driving accidents. These funds may be used for medical expenses, counseling, or to replace lost wages. The funds cannot be used for property damage, or as compensation for pain and suffering. In order to be eligible, the crime must have occurred in Pennsylvania, must have been reported within 72 hours, and the claimant must have cooperated in the investigation. Claims must be filed within one year of the event.
The Crime Victims Compensation Fund is a “payer of last resort,” and all other sources must be exhausted before payment is made.
Public Benefits: Federal Government
The primary source of federal funds that may be available for the catastrophically injured is through Social Security.
The Social Security system is a government retirement program that all workers pay into during their working years. The Social Security system can be complicated, particularly those programs that are available for disabled workers, but it might be helpful to bear in mind that the fundamental idea is really a very simple one: if a worker becomes disabled and unable to work, the Social Security system allows that person to access their benefits earlier than they would otherwise be able to.
Social Security for adults
The Social Security Administration administers two very different programs that may provide funding sources for people with serious injuries or other disabling medical conditions: the Social Security Disability Insurance (SSDI) program and the Supplemental Security Income (SSI) program. These programs are sometimes referred to by the title number given to the program under the Social Security Act, which is the law that creates the benefit programs. SSDI benefits are called Title II (2) benefits and SSI benefits are called Title XVI (16) benefits.
Both programs require that the injured person establish, through competent medical evidence, that he/she is disabled. Disability is defined as:
Inability to engage in substantial gainful activity, by reason of a medically determinable physical or mental impairment(s) which can be expected to last for a continuous period of not less than 12 months.
The SSDI and SSI programs use the same definition of disability, but the other eligibility requirements are different.
SSI eligibility is based on disability, income, and resources – that is, a disabled person is entitled to receive these benefits if his or her household income and assets fall below a certain level, regardless of whether the individual ever worked. The household income limit depends upon the number of individuals living in the household. Currently, an applicant who lives on his or her own must have an income of no more than approximately $500 per month (the limit is approximately $750 for a couple living together) and total assets of no more than $2,000 ($3,000 per couple), excluding the applicant’s residence, car, certain life insurance policies, and burial plots. If eligibility for SSI is established, the program entitles the patient to Medicaid, payment of Medicare insurance premiums, food stamps and other social services administered through the state’s Department of Public Welfare.
SSDI eligibility is based on work and earnings history. To be eligible, an individual must have earned a minimum number of “work credits,” which are based on income levels in prior years. For most applicants, some of the credits must have been earned in recent years. In general, an applicant over the age of 30 must have worked for 5 out of the last 10 years of employment prior to the onset of disability. A quarter (a three-month period) is counted toward this total if the amount earned exceeds a minimum threshold (as of 2005, this figure is $950 per quarter). An individual who becomes disabled before age 31 must have worked for half the number of quarters between the date the applicant turned 21 and the date of disability, but not less than six quarters.
The amount of the SSDI benefit is based on the applicant’s earnings history. The benefit that an individual is entitled to receive is called the Primary Insurance Amount (“PIA”), and is generally the same amount that individuals would have received at age 65 based upon the existing work history. However, SSDI benefits may be reduced if an individual is receiving or has received (in the recent past) workers’ compensation benefits. In general, Social Security only allows a disabled individual to collect, through combined Social Security and Workers’ Compensation benefits, up to 80% of the largest yearly earnings in the five years prior to disability. The closer the workers’ compensation benefits are to this 80% figure, the smaller the amount of the SSDI benefits.
Family members who are dependents of an individual receiving SSDI benefits may also be eligible to apply for benefits. The maximum amount that a family can receive is 150% of the PIA amount. There are many limitations on benefits available to dependent family members. Eligibility for the family benefit is limited to non-disabled spouses who are 62 or older or who are caring for a child under the age of 16. Non-disabled children are eligible for benefits under this program until the age of 18, or 19 if still in high school. Disabled children over age 19 may be eligible for SSDI benefits on a parent’s account. Earnings by a non-disabled spouse may affect eligibility for these benefits.
SSDI benefits have a waiting period of five full calendar months, measured from the date of onset established by the Social Security Administration. These benefits are retroactive up to a maximum of 12 months prior to the initial application for benefits. If you apply for benefits before the end of the five-month waiting period and are awarded benefits, the benefits will not commence until the end of the five-month waiting period.
Recipients of SSDI are eligible for Medicare, but only after they have received SSD for two years or more, or if they are over 65. Medicare premiums are automatically deducted from the monthly benefits.
In some cases, individuals are eligible for both SSD and SSDI. Those individuals whose SSDI benefits are lower than the amount of SSI benefits can apply for SSI to increase the total benefits up to the level that would otherwise be paid by SSI. People who qualify for both SSDI and SSI become immediately eligible for medicaid / medical assistance. (This can be important, because medicaid / medical assistance coverage is generally broader than medicare coverage.)
The decision about when to apply, and which program to apply to, is an important one. Timing depends in part on the type and severity of the injury or disability. Generally, if there is medical evidence that the disability will continue for at least 12 months, one can apply immediately. If the medical evidence about the length of disability is unclear, then it might make sense to apply once medical evidence becomes available indicating that the disability period will exceed 12 continuous months.
With proper documentation and medical support, claims for Social Security benefits can sometimes be approved when they are first presented to the Social Security Administration. Often an individual can prepare the initial paperwork and gather the required medical information. It is important to bear in mind that the paperwork needs to be completed fully and accurately, and that the medical information that is submitted with the application needs to clearly indicate the individual’s disabling condition and any physical and mental limitations. It can be helpful to have these materials reviewed by an attorney who specializes in this area of the law, to make sure that the paperwork and medical documentation are in order, and to ensure that there are no issues that may cause problems in the event of an adverse initial decision and subsequent appeal.
Typically, the Social Security Administration’s initial response to an application is to deny the claim. These adverse decisions must be challenged through an administrative appeals process. The appeals process can be complicated and lengthy, and it is helpful to have the assistance of an attorney who specializes in this complicated area of the law.
The Social Security Administration recently initiated a new program called the “Ticket to Work,” which provides additional choices and opportunities for disabled individuals returning to the work force. Information can be found online at http://www.yourtickettowork.com, or by dialing 1-866-968-7842 or 1-866-833-2967 (TTY).
Social Security for Children
Children with disabilities may be eligible for SSI. A child qualifies as disabled if he or she has a medically determinable impairment (physical or mental) that causes marked or severe functional limitations for more than one year, or is likely to result in death. The Social Security Administration considers the cumulative affects of an impairment. Therefore, some functional limitations in a few different areas will be considered cumulatively.
The amount of SSI a child may receive depends on his or her parents’ income. Generally speaking, the parents’ income must be relatively modest in order for the child to receive SSI. Income eligibility is determined using a complex formula that accounts for many deductibles. Also, a parents’ assets (such as a savings account) can operate to make the child ineligible for payments if the child lives with the parent. If the parent is receiving public assistance, those payments are not considered in calculating the child’s eligibility. topy
Housing
Sometimes, accommodations to a home or apartment are necessary if a disabled individual is to return to their home or to their community. For example, doorways and entryways may need to be widened to accommodate wheelchairs, and a few simple but significant modifications may be necessary to make bathrooms functional.
Under the Fair Housing Amendments Act of 1988, a landlord is required to allow a disabled individual to alter their home at the individual’s expense. The landlord is allowed to require that the restorations be performed in a workmanlike manner, and can require the renter to create an escrow account to provide for restoring the residence to its original state.
There are two basic forms of housing assistance: public housing units (mostly rental units) and Section 8 vouchers for private rental units. Both programs are administered through the Housing Authority, and both often have waiting lists. The programs are subject to household income requirements.
Individuals using Section 8 vouchers for private rental units only pay 30% of their income towards housing; the voucher covers the difference between that amount and the fair market value for the unit. Because vouchers allow disabled individuals to live in private housing which is normally better integrated with the community, they are usually considered preferable. The waiting list for Section 8 vouchers is currently closed, but will open for the addition of new names at brief intervals. These waiting lists must be closely watched! If you need housing assistance, you should contact the Housing Authority first so that your name can be added to the mailing list.
The Housing Authority also operates, and usually owns, its own housing units.
Federal laws, such as the Federal Fair Housing, Act Section 504 of the Rehabilitation Act, provide requirements that state and local housing authorities must follow for making federally funded housing available for persons with disabilities. While Philadelphia has many accessible housing units, Philadelphia has done a poor job of ensuring that accessible units are actually occupied by persons with disabilities. If a client has identified a particular housing option and has been denied housing either on the basis of the disability or the housing authority’s failure to prioritize a disabled applicant when required to do so, litigation my be appropriate. In addition, if an individual believes that he or she has been mistreated by a public housing official, a claim can be lodged with the Pennsylvania Human Relations Commission or the Office of Housing and Urban Development. top
Here is some housing contact information:
Philadelphia Housing Authority
642 North Broad Street
Philadelphia, Pennsylvania
Housing Consortium for Disabled Individuals (Services)
4701 Pine Street
Philadelphia, PA 19143
215-528-5847
Public Interest Law Center of Philadelphia (discrimination claims)
125 South 9th Street, Suite 700
Philadelphia, PA 19107
215-627-7100
Fair Housing Council of Montgomery County
105 East Glenside Avenue, Suite E
Glenside, PA 19003
215-576-7711
Pennsylvania Human Relations Commission
Pennsylvania State Office Building, Room 711
Broad and Spring Garden Streets
Philadelphia, PA 19130
215-560-2496
United States Department of Housing and Urban Development
Office of Fair Housing and Equal Opportunity
The Wanamaker Building
100 Penn Square East
Philadelphia, PA 19107
1-800-669-9777
1-800-927-9275 (TDD)
Self-Determination Housing Project
119 South Easton Road
Glenside, PA 19038
215-884-2091
Public Benefits: Attendant Care
Many victims of catastrophic injuries require assistance with their basic activities of daily living and their medical care. Attendant care services can be vital for these patients. The availability of attendant care often can make the difference between a patient living at home and a patient needing to live in an institution.
The Pennsylvania Department of Public Welfare administers two programs that provide funding for in-home attendant care, Act 150 and the Medicaid Waiver program. Both programs have age, citizenship/residency, disability and medical need requirements. DPW contracts with various area attendant care organizations who perform eligibility review and provide attendant care workers.
The two programs have different financial eligibility requirements. The Medicaid Waiver program is available for those who require nursing home level care but choose to live in the community and who have a gross monthly income of 300% of the SSI benefit rate or less. Anyone eligible for SSI or Medical Assistance is eligible for the Act 150 program. Patients who have incomes over the SSI benefit rate are also eligible, but must pay a fee determined by a sliding scale based on their level of income. Application for the two programs can be accomplished through attendant care contractors.
A complete list of Pennsylvania attendant care contractors is available through http://www.libertyresources.org .
Contractors in the southeastern Pennsylvania area include:
Abilities in Motion
416 Blair Avenue
Reading, PA 19601
888-376-0120
(610) 288-2301 (TTY)
http://www.abilitiesinmotion.org/
Citizens for Independence and Access
3450 Industrial Highway
York, PA 17402-9307
(717) 840-9653
Freedom Valley Disability Enablement
3607 Chapel Road
Newtown Square, PA 19073
(610) 353-6640
(800) 427-4754 (TTY)
(610) 353-6753 (FAX)
Homemaker Service of Metropolitan Area, Inc.
444 N. 3rd Street, Suite 202
Philadelphia, PA 19123
(215) 592-0002
Jewish Employment and Vocational Service
1845 Walnut Street, 7th Floor
Philadelphia, PA 19103
(215) 854-1800
http://www.jevs.org/contact.asp
Lehigh Valley Center for Independence
919 S. 9th Street
Allentown, PA 18103
(610) 770-9781
Liberty Resources, Inc.
1341 N. Delaware Avenue, Suite 105
Philadelphia, PA 19125-4314
(215) 634-2000
www.libertyresources.org/pas_contractor.html
United Disabilities Services (UDS)
formerly
United Cerebral Palsy of Lancaster County
1901 Homestead Lane
P.O. Box 10485
Lancaster, PA 17605-0485
(717) 397-1841
(800) 995-9581
(717) 293-1595 (FAX)
Disabled Children
As indicated elsewhere, both state and federal programs provide specific benefits for children with disabilities. Where a catastrophically injured individual is a child, these additional benefits may be of significant help to the child or his/her family. In addition to health care and disability programs, children with significant disabilities have rights under the federal Individuals With Disabilities Education Act (IDEA). This Act requires states to provide a variety of services to children with disabilities as part of an “appropriate public education”. Services available include early intervention programs for children less than school age. Once a disabled child reaches school age, services such as transportation, certain types of therapies, equipment and special education programs are or should be made available pursuant to an Individualized Educational Plan (IEP). Because the services are part of an “appropriate public education,” they are free to the child and his/her family. However, problems can arise during the development or implementation of the program for a specific child, and sometimes it is helpful if the child has an advocate. Sometimes, litigation is necessary to ensure that a child’s rights to an appropriate education are enforced.
The following are important sources of information, and also places to look for support and expertise in this area.
Education Law Center
1315 Walnut Street
4th Floor Philadelphia
PA 19107
215-238-6970
215-772-3125 (fax)
215 789-2498 (TTD)
Legal Clinic for the Disabled
1513 Race Street Philadelphia,
PA 19102
215-587-3350 215-587-3166
(fax) 215-587-3352 (TTY)
http://www.legalclinicforthedisabled.org/
Rehabilitation Hospitals & Facilities
When a person suffers a catastrophic injury, whether a brain injury, a spinal cord injury, loss of limbs or severe burns, acute medical care for the injury is only part of the healing and recovery process. Many of these patients require long term rehabilitation care to enable them to achieve the highest measure of recovery their injuries will permit. The Philadelphia area has many hospitals and facilities that offer an extensive range of inpatient and outpatient rehabilitative services including physical and occupational therapy, speech therapy, recreational programs and support groups. These facilities generally have programs tailored to provide appropriate rehabilitation therapy for different types of catastrophic injuries. Some of the primary hospital facilities in the Philadelphia area are:
Bryn Mawr Rehabilitation Hospital
414 Paoli Pike
Malvern, PA 19355
(610) 520-2605
Magee Rehabilitation Hospital
6 Franklin Plaza
Philadelphia, PA 19102
Admissions Office:
(215) 587-3117
Moss Rehabilitation Hospital
1200 W. Tabor Road
Philadelphia, PA 19141
(215) 456-9900
In addition to these hospital-based rehabilitation facilities, there are a large number of inpatient and outpatient rehabilitation facilities, some of which are contained in the list of resources at the end of this guide. Nurse case managers are often very familiar with these facilities and can provide useful contact information. Some of those facilities are:
Bacharach Institute for Rehabilitation
61 W. Jimmie Leeds Road
Pomona, NJ 08240
(609) 652-7000
Bancroft Rehabilitation Services
Hopkins Lane
P. O. Box 20
Haddonfield, NJ 08033-0018
(856) 429-0010
Beechwood Rehabilitation Services
469 East Maple Avenue
Langhorne, PA 19047
(215) 750-4299
(800) 782-3299
http://www.beechwoodrehab.com/
JFK Johnson Rehabilitation
Center
for Head Injury
The Outpatient Center at Oak Tree Road
2050 Oak Tree Road Edison,
NJ 08818
(732) 906-2640 (Cognitive Rehabilitation)
(732) 548-7610 (Pediatric Rehabilitation)
Remed of Philadelphia
625 Ridge Pike, Building C
Conshohocken, PA 19428
(610) 834-1300
St. Lawrence Rehabilitation Center
2381 Lawrenceville Road
Lawrenceville, NJ 08648
(609) 896-9500
Voorhees Pediatric Rehabilitation Hospital
92 Brick Road
Marlton, NJ 08053
(856) 489-4520
Vocational Rehabilitation Services
Even in the face of catastrophic injuries, many patients can recover and be rehabilitated to the point where they can re-enter the work force. Vocational rehabilitation is rehabilitation that is designed to help people with injuries or disabilities return to work (or, in some cases, start work). In Pennsylvania, the Office of Vocational Rehabilitation provides and coordinates services that prepare disabled individuals to re-enter the job market. Not all services provided by OVR are free.
The Pennsylvania Office of Vocational Rehabilitation may be contacted:
The Pennsylvania Office of Vocational Rehabilitation
1300 Labor Industry Building
Harrisburg, PA 17120
(717) 787-5233
Philadelphia Office of Vocational Rehabilitation
444 N. Third Street
5th Floor Philadelphia, PA 19123
(215) 560-1900
(215) 560-6144 (TTY)
(800) 442-6381
Bucks Montgomery, Chester & Delaware
Valley
Office of Vocational Rehabilitation
Rosemont District Office
1062 E. Lancaster Avenue
Rosemont, PA 19010
(610) 525- 1810
(610) 525-5835
(TTY) (800) 221-1042
Civil Litigation:Claims for Damages
Catastrophic injuries are, by definition, the result of some event or series of events that are usually, but not always, accidental in nature. Accidental catastrophic injuries are often the result of some wrongful conduct or act, frequently by a third-party, not the injured individual, that may be held legally responsible for the injuries caused. Catastrophic injuries can be the result of automobile accidents, work place injuries, dangerous conditions on property, medical malpractice, defective products, or other types of acts for which someone may be held legally responsible. Theoretically, the law permits a person injured as the result of another’s conduct or act to recover compensation for, among other things, past and future medical expenses, lost earnings or earnings capacity, and the pain and suffering the injured individual has endured. Recovery of damages is dependent upon being able to prove that someone other than the injured person is responsible for the injury. This type of claim almost always requires substantial and significant litigation. Competent, effective legal representation is essential to investigate and prosecute this type of civil litigation.
You should check insurance policies to see whether any of these coverages are available.
As trial lawyers, our focus is always on the courtroom, and on the work necessary to prepare cases for the courtroom.
As part of that work, we have had the opportunity to witness firsthand the efforts of clients and families struggling to piece lives back together after sometimes enormous setbacks. Sometimes, tort litigation -- that is, a lawsuit against a company or a person that caused an injury as a result of carelessness or other misconduct -- can effectively secure the resources necessary to provide the highest quality of life. But litigation proceeds are not the only potential source of resources for accident victims. Many different private and public benefits and resources are potentially available.
RESOURCES
Amputee Resource Foundation of America, Inc. (ARFA)
6480 Wayzata Boulevard
Golden Valley, MN 55426 (612) 812-7875
http://www.amputeeresource.org/
Brain Injury Association, Inc.
105 N. Alfred Street
Alexandria, VA 22314 (703) 236-6000 (800) 444-6443
Brain Injury Association of Delaware
P. O. Box 95
Middletown, DE 19709
(302) 537-5770
(800) 411-0505
Brain Injury Association of New Jersey, Inc.
1090 King George Post Road, Suite 708
Edison, NJ 08837
(732) 738-1002
(800) 669-4323
Brain Injury Association of Pennsylvania
2400 Park Drive
Harrisburg, PA 17110
(717) 657-3601
(866) 635-7097 (In state)
Brain Injury Resource Center
212 Pioneer Building
Seattle, WA 98104-2221
(206) 621-8558
Legal Clinic for the Disabled, Inc.
Magee Rehabilitation Hospital
1513 Race Street
Philadelphia, PA 19102
(215) 587-3350
http://www.legalclinicforthedisabled.org
Magee Rehabilitation Hospital
6 Franklin Plaza
Philadelphia, PA 19102
Admissions Office: (215) 587-3117
MossRehab Resource Net (MRRN)
Moss Rehab Hospital
1200 W. Tabor Road
Philadelphia, PA 19141
(215) 456-9900
http://www.mossresourcenet.org/
National Association of Home Care & Hospice
228 Seventh Street, S.E.
Washington, D.C. 20003(202) 547-7424
National Family Caregiver Association
10400 Connecticut Avenue, #500
Kensington, MD 20895-3944
(800) 896-3650
National Industries for the Severely Handicapped (NISH)
East Regional Office
P. O. Box 686
2236-C Gallows Road
Dunn Loring, VA 22027
(517) 226-4600
National Institute of Neurological Disorders & Stroke (NINDS)
National Institutes of Health
Bethesda, MD 20892
www.ninds.nih.gov/health_and_medical/disorders/tbi_doc.htm
National Spinal Cord Injury Association (NSCIA)
6701 Democracy Boulevard, Suite 300-9
Bethesda, MD 20817
(301) 588-6959
(301) 962-9629
Philadelphia Corporation for Aging
642 N. Broad Street
Philadelphia, PA 19130
(215) 765-9000
United States Department of Justice
American With Disabilities Act Information Line
1-800-514-0301
1-800-514-0383 (TDD)
www.usdoj.gov/crt/ada/infoline.htm
Support Groups
Amputee Resource Foundation of America, Inc. (ARFA)
6480 Wayzata Boulevard
Golden Valley, MN 55426
(612) 812-7875
http://www.amputeeresource.org/
Brain Injury Association, Inc.
105 N. Alfred Street
Alexandria, VA 22314
(703) 236-6000
(800) 444-6443
Brain Injury Association of Delaware
P. O. Box 95
Middletown,
DE 19709
(302) 537-5770
(800) 411-0505
Brain Injury Association of New Jersey, Inc.
1090 King George Post Road, Suite 708
Edison, NJ 08837
(732) 738-1002
(800) 669-4323
Brain Injury Association of Pennsylvania
2400 Park Drive Harrisburg,
PA 17110
(717) 657-3601
(866) 635-7097 (In state)
Brain Injury Resource Center
212 Pioneer Building
Seattle, WA 98104-2221
(206) 621-8558
Legal Clinic for the Disabled, Inc.
Magee Rehabilitation Hospital
1513 Race Street
Philadelphia, PA 19102
(215) 587-3350
http://www.legalclinicforthedisabled.org
Magee Rehabilitation Hospital
6 Franklin Plaza
Philadelphia, PA 19102
Admissions Office: (215) 587-3117
MossRehab Resource Net (MRRN)
Moss Rehab Hospital
1200 W. Tabor Road
Philadelphia, PA 19141
(215) 456-9900
http://www.mossresourcenet.org/
National Association of Home Care & Hospice
228 Seventh Street,
S.E. Washington, D.C.20003
(202) 547-7424
National Family Caregiver Association
10400 Connecticut Avenue,
#500 Kensington, MD 20895-3944
(800) 896-3650
National Industries for the Severely Handicapped (NISH)
East Regional Office
P. O. Box 686 2236-C Gallows Road
Dunn Loring, VA 22027
(517) 226-4600
National Institute of Neurological Disorders & Stroke (NINDS)
National Institutes of Health Bethesda, MD 20892
www.ninds.nih.gov/health_and_medical/disorders/tbi_doc.htm
National Spinal Cord Injury Association (NSCIA)
6701 Democracy Boulevard, Suite 300-9
Bethesda, MD 20817
(301) 588-6959 (301) 962-9629
Philadelphia Corporation for Aging
642 N. Broad Street
Philadelphia, PA 19130
(215) 765-9000
United States Department of Justice American
With Disabilities Act Information Line
1-800-514-0301
1-800-514-0383 (TDD)
www.usdoj.gov/crt/ada/infoline.htm
Entitlements And Benefits
Bucks, Montgomery Chester & Delaware Valley Office of Vocational Rehabilitation Rosemont District Office
1062 E. Lancaster Avenue
Rosemont, PA 19010
(610) 525- 1810 (610) 525-5835 (TTY) (800) 221-1042
Childrens Health Insurance Program
Healthy Kids Hotline
(877) 543-7669
(PA Only)
(800) 735-2258 (TTY)
Healthcare Financing Administration (HCFA)
Medicare Consumer Information
(215) 861-4226
Medicaid Childrens Health Insurance Program
(CHIP) (800) 842-2020
New Jersey Division of Vocational
Rehabilitation Services
135 East State Street
P. O. Box 398 Trenton, NJ 08625
(609) 292-5987
(609) 292-2919 (TTY)
Pennsylvania Bureau of Workers Compensation
1171 S. Cameron Street,
Room 324
Harrisburg, PA
17104-2501
(717) 783-5421
http://www.dli.state.pa.us/bwc
Pennsylvania Bureau of Workers Compensation
Philadelphia District Office
1400 Spring Garden Street, 15th Floor
Philadelphia, PA 19130
(215) 560-2488
Pennsylvania Office of Vocational Rehabilitation
1300 Labor Industry Building
Harrisburg, PA 17120
(717) 787-5244
Philadelphia Office of Vocational Rehabilitation
444 N. Third Street, 5th Floor Philadelphia,
PA 19123
(215) 560-1900
(215) 560-6144
(TTY) (800) 442-6381
Social Security Administration Office of Disability
(800) 772-1213 (800) 325-0778 (TTY)
United States Department of Housing & Urban Development
Support Housing for Persons With Disabilities
51 7th Street, S.W.
Washington, D.C. 20410
(202) 708-1102 (202) 708-1455 (TTY)
Acknowledgements
We are deeply indebted to the Legal Clinic for the Disabled, http://www.legalclinicforthedisabled.org/, and its Executive Director, Thomas Prettyman, Esquire, for lending some of their enormous expertise to this guide. The Legal Clinic for the Disabled is a not-for-profit corporation that specializes in providing free legal services to low-income people with physical disabilities in Philadelphia and the surrounding counties.
Additional contact information for the Legal Clinic for the Disabled is set forth above. We are also indebted, in equal measure, to Meyer Silver, Esquire, of the law firm Silver & Silver, and his colleagues at that firm, for lending their knowledge of Social Security disability law. Silver & Silver is a law firm that is widely, and justly, recognized for its expertise in this important and highly specialized area. Mr. Silvers can be contacted at (610) 658-1900.)
