Accident Victim Denied Treatment by HMO, Arbitration Denies Him Justice

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® Patient’s Medical History: Louis DeGeorge first ran into problems with his HMO when he suffered major dental damage in an automobile accident in 1995 at the age of 68. Louis suffered spinal and hip injuries, as well as 11 splintered teeth.

From the accident scene, Louis was taken to a non-HMO emergency room that did not have an x-ray apparatus for teeth. Louis was told to call his HMO primary care physician for treatment of his teeth. Louis’s HMO primary care physician could not see him for week. When Louis tried to get a referral to another HMO-covered dentist, he had no luck. He called more then twenty times and sent the HMO a letter but got no response.

Desperate, Louis picked a dentist out of the phone book and incurred almost $26,000 in dentistry bills. For over two years, Louis tried to get his teeth repairs covered by his HMO, but was denied because he had gone out-of-network for treatment.

ARBITRATION STORY- Upset at his HMO for his treatment and the unpaid bills, Louis decided to file a grievance against the company. Louis was told by the HMO that his only option was to go to arbitration with the HMO. Louis was leery of an arbitration where the arbitrator was contracted by the HMO, but he was forced to agree to the hearing because, he claims, the HMO threatened that he would be disenrolled if he did not attend. Louis knew that arbitration was his only option to recover the $26,000 for his teeth repairs so he decided to go through with the hearing.

Louis began the arbitration process with the HMO, but could not afford an attorney. He knew he had to face experienced attorneys representing the HMO, but decided to represent himself because it was his only option.

Five years after he began the appeals process with the HMO, Louis finally had his HMO hearing. Louis complains that the neutral hearing was held in the HMO’s office, so it was "not a neutral setting to say the least."

Louis claims that though he was representing himself, the HMO told him a week before the arbitration that an additional HMO lawyer and HMO apokesperson would be present. To protect himself Louis brought a friend of his own along as a witness. At the hearing, Louis states the arbitrator let the HMO lawyer cross examine when he should not have been able to. Louis believes because the arbitrator was often contracted by the HMO he allowed the HMO lawyer to do this, and generally control the proceedings. Louis feels that the arbitrator wants to be used by the HMO repeatedly, so the arbitrator has more of an incentive to arbitrate and decide in the HMO’s favor than in the patient’s.

During the hearing, one of the HMO representatives asked Louis what his high and low settlement amount demands were. Louis gave him the figures and the HMO representative left the room. Upon his return, the HMO representative told Louis the company was aware that Louis had sent letters to politicians and the media about his ordeal. The company told Louis that they wanted him to stop these actions and in turn Louis was offered a settlement. The settlement amounted to about a third of what he wanted and not even enough to cover his dental bills. Again, Louis claims the HMO threatened that he take the settlement or would be disenrolled and get nothing. Intimidated by the arbitration proceedings and the HMO’s threats, Louis decided to take the settlement.

When the settlement agreement was given to Louis he noticed a confidentiality agreement in it. Upset with the fact that he would be prevented from disclosing details of the HMO’s actions, Louis decided to turn down the settlement and has currently received no money from the HMO and is awaiting disenrollment.

Reflecting back, Louis states the HMO arbitration was biased towards the HMO. Louis states, "I want all seniors to know how to keep from getting scammed. When you have an arbitration you are delaying your treatment. What do you do in the meantime while you are waiting? Your health needs immediate care now. And if the HMO denies you care that injures your health you should be able to sue them forthwith without going to arbitration."

— Louis DeGeorge reports his own story.

FTCR will continue to fax daily a story of HMO Arbitration Abuse to educate the public on the need for reform. AB 1751 (Kuehl) makes HMO binding arbitration voluntary rather than mandatory.

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