HMO Refuses to Provide Standard Medical Procedure, Family’s Costly Arbitration Lost

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® Patient’s Medical History: The dispute between Betty Woolfson and her HMO arose when the HMO’s doctors recommended a course of treatment that world-renowned neurosurgeons at UCLA Medical Center believed would endanger her life. Betty’s family had decided to get a second opinion because Betty’s condition was so serious.

The estimated cost for the surgery and treatment UCLA doctors recommended was $150,000, with advance payment required. The UCLA doctors stressed the seriousness of Betty’s condition and immediate need for surgery.

Betty had an artery in her brain the diameter of a golf ball that was calcified, brittle and full of blood clots. It had already caused Betty to go blind in one eye, and there was the constant threat of complete vision loss, massive stroke or death.

Betty’s HMO postponed the life-saving surgery numerous times because the company refused to pay for it. Betty’s family decided to file a grievance against the HMO for the denial of surgery.

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

Sarah continues, "Unable to reach an agreement with the HMO, we tried 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."

STOCKTON, CA- Sarah states, "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."

Betty entered into arbitration and had to pay $40,000 right away for legal fees, witnesses and an arbitrator who, Sarah complains, had no medical background.

Sarah claims the HMO then delayed and prolonged the process, in order that Betty’s age would qualify her to have Medicare pay for the surgery. When Betty reached that age, she had no choice but to join Medicare and have the life-threatening condition taken care of, having already suffering additional damage to her remaining good eye.

Sarah explains, "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. We were not looking for coverage of an experimental treatment or anything. This surgery was a standard medical procedure."

Betty’s family had exhausted all their efforts in arbitration at this point. Faced with the prospect of spending another $40,000 – $60,000 to compete with the HMO, Betty’s family put their decision in the arbitrator’s hands. The arbitrator would decide in favor of the HMO.

Sarah states, "Arbitration is a daunting process, set up to favor the HMO, not the patient. The HMO has huge amounts of money and was able to get any expert witness they needed while we had the burden of trying to convince experts to help us."

Sarah explains, " I often tell people if you want to have HMO coverage, I hope you have $40,000 – $50,000 in the bank because that is what you will have to spend if you go into arbitration with the company. You will be going against a team of HMO lawyers trying to wear you down. It becomes a bottom line decision when the HMO figures whatever amount they spend to defeat you, they will still come out ahead if it is less than the cost of your care."

— Betty Woolfson’s story is reported by her daughter, Sarah Jones.

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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