HMO Refuses To Pay For Life Saving Surgery

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Betty Woolfson – Stockton, CA

As told by her daughter, Sarah Jones:

HMO enrollees who get an outside doctor’s opinion had better have deep pockets to pay for the medical help they need. So far, a dispute between outside doctors and my mother’s HMO has cost our family more than $15,000 in legal fees. My mother is in critical need of life-saving surgery that has already been postponed three times because her HMO refuses to pay for it.

The dispute between my mother and her HMO arose when the HMO’s doctors recommended a course of treatment that world-renowned neurosurgeons at UCLA Medical Center believe will endanger her life. We wanted a second opinion, because my mom has an artery in her brain the diameter of a golf ball that is calcified, brittle and full of blood clots. It has caused her to go blind in one eye. At any time she could completely lose her sight suffer a massive stroke, or die.

The estimated cost for the surgery and treatment UCLA doctors recommend is $150,000 and advance payment is required. UCLA doctors believe my mother’s condition is serious and that surgery must be performed as soon possible.

Initially, my mom’s HMO stated there is no appeal process. Finally, someone explained there was no "complaint department", only a "customer satisfaction department."

Unable to reach an agreement with the HMO, we had to take our case to Federal Court. At this point, my mother, a middle aged, lower income woman with no connections was given the responsibility to convince top specialists to take a day off from brain surgery to fly 500 miles to testify on her behalf. She was unable to persuade the experts to come to court and the HMO suggested we enter into the arbitration process.

By law, arbitration requires that each side pay their costs, when an HMO is involved, regardless of who wins. By the sheer fact that HMOs have endless financial resources, this makes it a cinch for HMOs to prevail. When this process bankrupts the patient, forcing them out of their HMO, it is often taxpayers that end up picking up the tab, saving the HMO from having to shell out for expensive medical procedures.

Sadly, our story is not unique. ERISA, the Employment Retirement Income Security Act, contains a loophole that allows HMOs to sidestep accountability for denying or delaying medical care. If this loophole were closed now, families like ours would not have to suffer financial and emotional ruin to get adequate medical help for our loved ones.

Consumer Watchdog
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