Ctamlouis Health

A city firefighter involved in an off-duty motorcycle crash in June was denied health insurance coverage for his injuries because the city’s health insurance required him to wear a helmet.

Lt. James Baker waited to see if the city council would accept a negotiated settlement this evening that would pay a reduced amount.

The Sebring City Council will meet at 6:30 p. m. today at 368 S. Commerce Ave. to vote on this and several other issues.

Baker suffered injuries from a motorcycle crash on U. S. 27 for which the medical claim came to about $86,000. He was airlifted to the Tampa General Hospital’s trauma center.

“I was out for a little less than two months,” said Baker. “I returned to full duty around the first of August 2009. “

Baker’s insurance claim was initially denied because a clause added to the city’s health insurance policy in 2005 on “activities of a hazardous nature,” excluded from coverage motor cycle accidents without helmets.

Baker claimed he would have been injured regardless of whether he wore a helmet, and thus the claim should be paid. He suffered mostly abdominal injuries and no head injuries, he said Monday.

In 1998 when he was hired, Baker said he received a copy of his insurance policy, and at time the exclusion clause was not there. He had no recollection of being notified that it was added, he added.

Had he known of the exclusion, he would have been wearing a helmet, he said.

At a city Health Insurance Committee meeting, City Clerk Kathy Haley said she was not sure if the notice of the added exclusions were handed out to city employees, the minutes of the meeting show.

Mayor George Hensley said a committee or an employee might consider different activities “hazardous. “
City Administrator Scott Noethlich agreed, but asked how one defined “hazardous. “

Representatives of the city’s health insurance administrator, Anchor Benefit, negotiated a settlement of $46,750, which they will have to pay.

At a special meeting held Feb. 25, the committee recommended that the council accept Anchor Benefit’s negotiated discount with the understanding that Baker pays his remaining out-of-pocket maximum for the year of $734. 74 and a $745 fee to negotiate the claims.

The tentative agreement further concluded that the basis of the recommendation was that Baker did not receive any head injuries and that he would have been injured even if he was wearing a helmet at the time of the crash.

However, it remains up to the city council to approve the deal.

Hensley said Monday that representatives of Anchor Benefit consulting had advised that this exclusion is not usually found in insurance policies, and Hensley believed the city would probably take a closer look at it.

Baker has since stopped riding a motorcycle, citing his love for his wife and five children.

He said that his wife told him while he was still in Tampa General Hospital that she knew how much he loved riding a motorcycle and she would not ask him to stop.

“That was a hobby,” said Baker. “I was ready to give it up, not to put my family through that again. “

On July 1, 2000, Florida exempted adult motorcyclists and moped riders from wearing helmets provided they have $10 000 in medical insurance, according to Andreas Muller, in the April 2004, American Journal of Public Health.

Since then, Florida statutes have required motorcycle riders younger than 21 years to wear helmets.

The statute was signed into law by former Gov. Jeb Bush.

Before that Florida had a helmet law that required all riders to wear safety helmets.

An Iowa health care provider is one of 85 community health centers nationwide to receive a significant monetary boost from the American Recovery and Reinvestment Act, President Barack Obama announced Wednesday.

“… Funding for construction, technology and a medical home demonstration project won’t just save more money, and create more jobs, they’ll give more people the peace of mind of knowing that health care will be there for them and their families when they need it. Ultimately, that’s what health reform is really all about,” Obama said.

Primary Health Care Inc. of Des Moines is slated to receive more than $2. 6 million. The nonprofit organization maintains dental and medical clinics in Des Moines as well as a community access pharmacy, HIV services and outreach project. It also operates a medical and dental clinic in Marshalltown.

Although the clinics provide services to patients who have insurance, they specifically cater to those who are uninsured or underinsured. According to their Web site, Primary Health Care Inc. strives “to find and successfully treat medical condition before they become serious enough to require hospitalization or emergency treatment. ”

It has also developed several specialized programs.

The Outreach Program specifically targets populations that often fall through the cracks in existing health care.

Health Care for the Homeless is a federally funded program that serves individual, families, street youth and homeless children in a non-traditional clinic setting. A federally-funded program called Enhancement provides mental health and substance abuse care for homeless clients.

The organization has also developed a four-point program for maternal child health that consists of a combination of state and federally-funded programs to provide service to pregnant women, newly expanding families and newborns up to age 6. Their Families in Transition program, which is funded through U. S. Housing and Urban Development, serves both prenatal or parenting families up to a child’s 15th birthday, and allows case workers to link homeless individuals to medical and mental health services as well as affordable and safe living environments.

Clinics that participate in the Outreach Program are located in six different sites throughout Des Moines, placing them within the areas of the community that are experiencing the most need.

To qualify for funding, the health facility had to be a federally-qualified community health center. Grants of $508. 5 million were provided through the Facility Investment Program to address pressing health center facility needs. Also, as much as $88 million was made available to help Health Center Controlled Networks improve operational effectiveness and clinical quality in health centers by providing management, financial, technology and clinical support services.

The new Recovery Act funds are the latest in a series of grants awarded to community health centers, which deliver preventive and primary care services nationally at more than 7,500 service delivery sites around the country to patients regardless of their ability to pay.   Across the country health centers serve more than 17 million patients, about 40 percent of whom have no health insurance.