Tenacity needed to get insurance plan to fix girl's wheelchair

Tenacity needed to get insurance plan to fix girl's wheelchair »Play Video
Helen Pendergraft, right, turned to KATU after the insurance plan refused to have the wheelchair fixed that her daughter, Ashley, uses. Ashley suffers from cerebral palsy.

PORTLAND, Ore. – Ashley Pendergraft just had her third operation in her 13 years of life.

She has a special wheelchair, but it broke.

Her mother, Helen, turned to KATU when the insurance plan refused to have it fixed.

It seems like it should be an easy thing to get fixed, but this case isn't that simple. It's not just any insurance plan. It's funded by taxpayers.

Ashley had surgery at Shriners Hospital for Children to correct her foot that was turning inward from cerebral palsy.

"She can take, at times, some little minor steps, but she is unstable and has to have a walker," her mother said.

The wheelchair Ashley's in now is a loaner from Shriners. The wheelchair she did have for the last two years was also donated to her through Shriners, but it broke.

Helen said she started crying at her mailbox when a letter arrived from her insurance, Willamette Valley Community Health. The letter said repairs to the chair were "not medically appropriate."

The taxpayer-funded insurance handles patients on the Oregon Health Plan in the Salem area.

The letter said Ashley's family could appeal. But why should they have to?

"It's a really messed up process, I think," Helen said.

Dean Andretta, the director of Ashley's health plan, is vowing to make the situation right. But it wasn't just his organization's doing. KATU News was told there were clerical errors made by people who do Ashley's health care, and even her mother didn't follow the appeals process all the way through.

"It's a process that was definitely broken in different spots in terms pf one particular entity getting the information all together, and that's precisely why we got to break this down and stop and sit down and talk – have the patients in-home primary care provider, the primary care physician and everybody get together with a long-term plan," he said.

The confusion in Ashley's case is exactly what Oregon's Gov. John Kitzhaber was hoping to eliminate. A year ago he announced a new way of doing state-funded health care by combining services to eliminate communication barriers.

There are growing pains with the new system, which can already seem overwhelming.

The insurance plan took a second look at Ashley's case after her doctors appealed with more paperwork. It said it will fix Ashley's wheelchair.

Getting rejected for health care services can seem overwhelming. There is an appeals process that Helen didn't fully understand.

The lesson is you have to fight for yourself and be your own advocate.

If you have a story for any of the On Your Side Investigators, email them at investigators@katu.com.