Patient’s Medical History: After being repeatedly denied an angiogram and hospital admittance for his heart condition by his HMO, Hal Riedel was forced "out-of-network" to receive an angiogram. The tests revealed Hal had five blockages in his heart and needed triple bypass surgery. Upon request for approval the HMO then denied the surgery for Hal. The surgery was performed the next day and proved to be a success, yet the Riedels were left with approximately $50,000 in "out-of-network" medical bills.
LAKEPORT, CA– The Riedels were forced into arbitration unknowingly by a clause in Hal’s coverage agreement. They struggled to get a hearing for over five years. They were shuffled between health plan administration, their personal doctor and their HMO’s "patient advocate" before they could begin the arbitration process.
After requesting a copy of Hal’s medical records, it was eight months before they received a set which only consisted of 11 pages.
The Riedels claim that before the arbitration process began their right to depose the HMO doctors was denied. Yet, according to Linda Riedel, the HMO was allowed to depose multiple parties. She states that one doctor the HMO was allowed to depose was not even introduced to the hearing until the night before depositions began. Still, the arbitrator allowed the doctor’s testimony.
Linda claims this doctor had no factual insight into Hal’s case, but was brought in by the HMO’s lawyer simply as a means to frustrate the Reidel’s attorney. Linda states that the HMO forced the arbitrator to allow the company an additional five depositions by various doctors, nurses and other employees of the HMO just 2 days before the hearing. According to Linda, none of these witnesses had pertinent to facts to add and just served to overburden the Reidel’s attorney.
Linda states that the HMO was allowed to give false information during the hearing even though phone record evidence refuted many of the company’s claims. The arbitrator claimed he felt Hal’s medical records were a little inaccurate but not falsified. The arbitrator instead blamed the Riedels for not calling the HMO to get authorization for Hal’s surgery, even though their doctor was in charge of that task.
The arbitrator also claimed Hal’s situation did not constitute an emergency even though, in notes, the out-of-network hospital had stated it was "emergent" and required admittance.
Overall, the Riedels feel the arbitration process was a waste of their time and money, though it was promoted by the HMO to take less time and money than a civil court case. They claim the HMO did all it could to delay the arbitration and deliberately frustrate them in their search for redress. The arbitration lasted a total of six years. The Riedel’s claim was dismissed on all counts. They spent $40,000 in attorneys fees in a failed attempt to recover the $50,000 in past due medical bills
Additionally, the Riedels claim the arbitration organization did not provide them a fair hearing. They complain of the financial incentives for arbitrators to not decide against the HMO and the inability of patients to track the decisions and time frames of past arbitrations. They feel that if they had the ability to have judicial review or could have had the decision publicly scrutinized, they may have been able to avert the unfair practices and falsifications by the HMO.
— Hal’s story is reported by his wife, Linda Riedel.
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.