HMO Denies $110,000 Surgery Recommended By Own Doctor, Patient Forced Into Debt

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Debra Moran – Winfield , IL

As told by Debra Moran:

My managed care nightmare began in July of 1995, when I developed pain in my hand, wrist, elbow, shoulder and neck. The pain proved to be a symptom of Brachial Plexopathy and Thoracic Outlet Syndrome — two related conditions that impair circulation and neural transmission. As the conditions worsened, the pain grew. But I continued to get the run-around from my HMO, which refused to refer me to the right specialists and denied coverage for the surgery that my HMO primary care physician deemed medically necessary.

In fact, I had to learn about my condition through my own research and an out-of-pocket evaluation by a specialist in Virginia. When this specialist confirmed diagnosis of the circulation and nerve damage, I returned to the HMO and asked for a referral to her. They took five months to deny the referral and I received no treatment in the interim. My pain grew worse. I could not cook, clean, go to work or feed myself.

After two and a half years of stonewalling by my HMO, the nerve in my neck and shoulder was scarred and destroyed. The out-of-the-HMO network specialist in Virginia recommended surgery to repair the nerve and restore circulation. The HMO denied payment for this $110,000 procedure, claiming it was not medically necessary, even though my pain was medically documented and my primary care doctor in the HMO concurred with the specialist. I mortgaged our future and our house, as well as our 401k, to pay for this surgery.

Today, I am well. The nerve and circulation damage is healing. The HMO would only pay for "hack and cut" surgery that would have cut into my neck, left me scarred and in pain, and taken years to recover. I would have never been better because the nerves were damaged and could not be left alone.

Until this day, my HMO refuses to pay for the procedure that saved my career and my quality of life. Because I receive health care through my husband’s employer, the HMO will never have to pay more than the cost of the procedure they were supposed to pay for in the first place. [And ERISA’s standard for proving an "arbitrary and capricious" denial to recover even those costs is much higher than the "medically necessary" standards under state law.]

Due to ERISA, the HMO will never have to pay damages for the pain they have caused or even my wage loss. If the HMO knew they would have to pay damages, I don’t think they would ever have treated me this way. I thought I had more rights, but instead I am paying huge credit card finance fees to pay off this procedure.

Consumer Watchdog
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