HMO Denies 9 Year Old Girl’s Tumor Surgery, Family’s Remedy Limited By Arbitration

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® Patient’s Medical History: "In January of 1993, when my 9 year old daughter, Carley, was diagnosed as having a rare and malignant kidney cancer, Wilms’ tumor, we were running against the clock in dealing with the crisis. The terms of the HMO we had just recently joined, instructed us to use a surgeon within the medical group we selected. Carley’s pediatrician, outside the HMO, and the federal advisory guidelines on Wilms’ tumors both insisted we use a pediatric specialist. The HMO list contained no such specialist, nor did it contain a surgeon who had done a single operation on a child with a tumor of this type.

Within a 12 hour period, my wife and I had to make a decision regarding our daughter’s life. Should we entrust this delicate, life-threatening operation to someone without prior experience in the field? Or, should we find an expert with a proven track record. We chose the latter course.

Carley’s successful surgery, recovery, and subsequent cure have assured us that we made the right choice. You only get one chance at removing a tumor correctly to insure the highest probability of survival.

What we discovered about our HMO and our rights in the aftermath of Carley’s operation produced an infuriating and frightening struggle against our HMO. The HMO called us while our daughter was still in intensive care, and informed us that they refused to pay any of the hospital bill."

WOODSIDE, CA- "Eleven months later, while Carley was going through painful chemotherapy treatments, an arbitrator ruled that the HMO must pay all the hospital and surgeon’s bills – everything except our legal expense – which by that time had reached five figures!

We learned that when we signed the HMO application, we gave up our seventh amendment right to trial by jury or any other legal remedies and had agreed to binding arbitration. Binding arbitration is part of the HMO grievance process – and one that favors the HMO. All the while, the HMO decision was medically indefensible!

In arguing our case with the arbitrator, we requested punitive and extracontractual damages for the agonizing eleven months the HMO put us through to recover our medical expenses that should have been paid by the HMO from the outset. The arbitrator chose to side with the HMO, so all the HMO had to pay was the medical expenses they should have paid in the first place. The HMO got away with leaving us to pay all the medical expenses for nearly a year, and their only punisment was to reimburse us for those medical expenses nearly 12 months later. That is categorically wrong!"

— Carley Christie’s story is reported by her father, Harry Christie.

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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