HMO Refuses Expensive Tests, Wife Does Own Research To Diagnose Ailing Husband

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Frank Dutcher – Azle, TX

As told by his wife, Deanna:

Since 1986, my husband, Frankie, worked line construction and took out electrical transformers. Polychlorinated Biphenls or PCB’s, a toxin, are found in these transformers and because of their health risk, must be replaced through attrition or when they are leaking. Liver dysfunction is a recognized symptom of PCB exposure.

My husband’s health problems started in 1988 when Frankie began to have infrequent black-out spells. By 1993 he was waking up with occasional nausea and dizziness, sometimes vomiting before he went to work. He had some swelling in his hands too.

We went to our family doctor and the tests showed elevations in his liver enzymes which meant that there was possible liver damage. The doctor never told us that at the time and just put Frankie on an anti-depressant, but his symptoms continued.

In 1995, Frankie had lost an unexplained 28 pounds in one month and woke up one morning vomiting violently. He went to his doctor and the tests revealed that those 1993 enzyme levels were worsening…it was the first we knew of them. Frankie was referred to a specialist who did a physical exam and asked about our family history. Due to Frankie’s symptoms, exam and discussion, the doctor expressed that he felt "it was very important that Mr. Dutcher have a liver biopsy as soon as possible." Yet, once the doctor realized which insurance provider we had, he abruptly changed his diagnosis.

In short, the doctors response was, "Let me tell you, you have bad insurance… dis-incentives through your HMO restrict the care given to patients on their plan." He suggested we report back to their our doctor

and have him order a CAT scan.

After explaining to the new physician Frankie’s history, symptoms and previous doctor’s diagnosis, the gastrointerologist claimed he did not believe the problem was related to the liver. Instead, the doctor felt his problems concerned the stomach and proceeded to test for ulcers. When the tests returned negative, we took out a $2,000 loan and went out of the HMO’s network.

On May 27, 1996, we finally received a diagnosis. The doctor did a physical exam, blood work and a CAT scan and informed us that "there were indeed other possible causes for fatty liver, toxins or certain drugs being among those causes."

Once the test results were back, our new doctor informed us that Frankie had "some very serious health problems including an enlarged heart and hardening of the arteries." Moreover, the doctor felt that "these conditions in a man of 31 years old warrant immediate attention."

With that diagnosis in hand, we changed HMO providers and started a new cycle of problems with our new HMO. Our new HMO sent us to two more doctors, one of which a claimed "there was no other possible cause for his condition other than his weight."

We learned more about the symptoms of PCB exposure, and pointed to those same symptoms in Frankie. But the doctors were more adamant that the PCBs were not the problem. Basically, if there are classic signs of liver damage in someone and you know that there is a direct pathway to PCB for that person, it would make sense to check out the liver.

We have been the victims of managed care. Everything we have learned about Frankie’s condition has come from outside our HMO network and has come at our own expense. We have been denied and delayed care and services, delayed and denied prescriptions, canceled by our primary doctor for requesting care, denied appropriate care, and finally even lied to in order to cover these problems up. We have been completely ignored in our attempts to complain to the HMOs involved.

I believe our HMO knows we have no legal remedy for denied or delayed care because of the ERISA loophole. Until HMOs are able to be held accountable for denied or delayed care, I am convinced that more people like Frankie and I will continue to suffer at the hands of managed care.

Consumer Watchdog
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