Patient’s Medical History: "My mother started having heartburn, bloating, gas and a nagging pain in her side in April / May 1996. She went to see her HMO physician in early June. This was followed by several visits over 3 months in which my mother continued to relate the same complaints. At no time was she referred to a specialist.
Finally, the HMO gave her a CT scan which revealed two areas of concern and she was referred to a gastro-intestinal specialist who performed a colonoscopy which revealed a large mass. An appointment with a surgeon was then scheduled and surgery was recommended to remove the mass.
I objected to the date of the surgery and asked that surgery be done sooner as my mother’s pain, discomfort and weakness were increasing daily. The HMO surgeon felt my mother could wait. That very evening my mother’s pain became intolerable and she went to the HMO’s Emergency Room via ambulance. She was not seen for one hour while being in the most excruciating pain. Only after waiting 4 hours, and my insistent demands, was my mother seen by a surgeon who decided to admit her.
Five more days passed before surgery and the HMO surgeon said her surgical need was not an emergency and could wait. Finally, after I pleaded with him, the surgery was done. Afterward the surgeon told us that she had a perforated ulcer which probably happened the night she was admitted to the E.R.! They had failed to diagnose it before the surgery. This perforated ulcer had obviously caused many internal problems.
Mother was now on a respirator and we were told that her prognosis was poor. My mother died a slow and agonizing death 4 weeks later due, in my opinion, to the HMO’s negligence and delay of care in not referring her to a specialist before she got so ill."
PLEASANTON, CA- Kathy decided to try to hold her mother’s HMO accountable for the negligent care provided her mother. After contacting a lawyer, only then did Kathy find out that disputes against the HMO were forced into private arbitration hearings.
Kathy’s lawyer warned her that arbitrations were very hard to win against the HMO because of the unlimited resources and influence the companies could exercise in the hearings. However, Kathy knew that her mother’s care was substandard and she wanted to prove it in arbitration.
Kathy began preparing for the arbitration process by requesting her mother’s medical records from the HMO. She had already had an original copy of the records but wanted a more recent version to see if there were any discrepancies by the HMO. She would have to request the records three times after multiple delays by the HMO, and finally give up after a year of not receiving them.
At the same time, Kathy had to pay for an expert witness who could testify on her mother’s substandard treatment. However, the HMO was able to produce numerous expert witnesses of their own. Kathy’s lawyer explained to her that in order to compete with the HMO they would need to pay for 1-2 more experts.
Already overextended financially in the arbitration, Kathy would have to make the decision she did not want to have to make. Having already spent $5000 on the initial expert, along with additional legal fees, Kathy was unable to produce the extra $15,000-$20,000 needed for the other experts. After nearly two years and thousands of dollars, Kathy dropped her claim against the HMO.
Kathy felt both emotionally and financially drained by the length and costs of the arbitration. She decided to try to find a lawyer to work on contingency for her. However, with the age of Kathy’s mother at the time of her death, and the futility of going against the HMO in another arbitration, no lawyers could take the case for Kathy.
— Betty’s story is reported by her daughter, Kathy Cailteaux.
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.