Judge Orders Nurse For Baby

A State Supreme Court Justice in Riverhead has ordered Oxford Health Plans, the health insurance company, to continue providing in-home nursing care for an East Hampton infant who, doctors say, could die without it.

The company has threatened to cut off the coverage. Its attorneys are scheduled to appear in court on Dec. 1 to argue the case.

Oxford, the managed-care company under contract to provide major medical coverage to the Casey family of Georgica Woods Lane, has been paying for intermittent in-home nurses for Christopher Casey, who was born on April 25, since his discharge about two weeks later from North Shore University Hospital.

Infant At Risk

Christopher was a patient at North Shore for about six weeks, where a team of a dozen specialists treated him for life-threatening congenital conditions, including esophageal reflex and apnea. Breathing stops and starts unpredictably in individuals who have apnea.

Because the baby was diagnosed as being at high risk for sudden infant death syndrome, his doctors recommended 24-hour nursing care.

Oxford, however, reduced the number of daily nursing hours it will cover from 12 to six, and has threatened, almost weekly, to cut off coverage entirely, according to Anne Casey, the child's mother.

Oxford's Response

In response to inquiries, Michael Barlow, the company's manager of "media relations," said Oxford was "making every effort to resolve these issues with the family and is providing nursing care pending the result of the legal proceeding."

Christopher and his mother were the subject of a July Star article recounting how Mary Ellen McMahon, an East Hampton Village public-safety dispatcher, and Mary Mott, an emergency medical technician, worked with Mrs. Casey to get the infant breathing again after he regurgitated his formula, choked, and became cyanotic - blue from oxygen deprivation.

Christopher was rushed to Southampton Hospital, where he remained for two days.

Dr. Barbara J. Cusumano of Southampton Pediatric Associates wrote twice to Oxford, reiterating her opinion that the infant "needs 24-hour nursing care" as neither parent is a medical professional, nor should they be "expected to act in that capacity."

Fear Of Infection

In a Sept. 19 letter, the doctor added, "I do not feel keeping a young infant in the hospital, as has been suggested by your company, is the answer either, because of the obvious detrimental effect this would have on an infant's development, as well as risk of nosocomial infection."

Nosocomial refers to infections patients may contract while in a hospital.

Mrs. Casey notes in legal papers that Oxford "insists that I can be trained to insert the suction tube deep into my son's trachea to clear it when it clogs and . . . to resuscitate in the event of respiratory arrest."

Justice Howard Berler issued a temporary restraining order on Nov. 6, forcing the insurance company to continue its nursing coverage. He issued a continuance of the order on Monday.

"Lethargic" At Birth

Christopher was born at St. Charles Hospital in Port Jefferson, after a 48-hour labor during which Mrs. Casey experienced bouts of abnormal bleeding. The baby was "lethargic" at birth, had difficulty nursing, and lost weight soon after.

Despite his mother's efforts to communicate to the medical staff that "something was wrong," the nurses said "I was just nervous," Mrs. Casey recalled. Mother and baby were discharged after the now-standard 48-hour stay, the baby weighing less than 5 pounds.

Stopped Breathing

Soon after their return to East Hampton, Christopher stopped breathing and went "limp," his mother said. After examining him at Southampton Hospital, Dr. Cus u mano referred the infant to specialists at North Shore.

Mrs. Casey recalled having "almost collapsed, with a newborn to be transferred, and I had to sit on the phone" to secure authorization from Oxford.

"If you're vulnerable, and don't get it together to call them," she observed this week, "they don't have to pay."

Deny Home Nursing

Mrs. Casey was referring to the common requirement by managed-care companies that patients and/or their families secure permission from a company administrative representative before being admitted to a hospital.

After the six-week hospitalization, Oxford denied the home nursing care. The couple decided to hire a nurse "on our own," starting with a night shift, as Mrs. Casey was unable to sleep.

Mrs. Casey said that soon after the Star article about Christopher's rescue appeared, Oxford "suddenly" agreed to cover a single 12-hour shift. That became eight hours, and now it is six.

"Every week, they say, 'This is the last week,'" the mother said. The cost of 24-hour private registered nursing care can be as high as $1,000 a day, she said.

High Costs

Meanwhile, the Caseys have spent more than $3,000 on special formula for the baby and $10 apiece for a variety of prescriptions and co-payments to physicians, totaling several hundred dollars. That is in addition to their annual insurance premium of more than $5,000 for family coverage under Oxford's "Freedom" plan, one of the insurer's top-of-the-line policies.

Mrs. Casey said the North Shore doctors told her they had "never seen a case like this."

"They still have no prognosis," she said. "The stress is enormous. I'm exhausted."

Mrs. Casey and her husband, Daniel, a contractor, also have a daughter, Katie, 41/2.