"Those HMO B*stards" - a very sad Xmas story. . .

[Porsche-O-Phile]

Just came across this on the news. Wow. Terrible story. The fallout/bad press/legal challenges from this ought to be interesting and precedent-setting in some respects.

I really feel for this family though - can you imagine going through the crap they've been through only to have their sister/daughter die days before Christmas?



http://www.cnn.com/2007/HEALTH/conditions/12/21/teen.liver.transplant.ap/index.html



Teen dies hours after liver transplant approved

GLENDALE, California (AP) -- A 17-year-old died just hours after her health insurance company reversed its decision not to pay for a liver transplant that doctors said the girl needed.

Nataline Sarkisyan died Thursday night at about 6 p.m. at University of California, Los Angeles, Medical Center. She had been in a vegetative state for weeks, said her mother, Hilda.

"She passed away, and the insurance (company) is responsible for this," she said.

"They took my daughter away from me," said Nataline's father, Krikor, who appeared at a news conference Friday with his 21-year-old son, Bedros.

Mark Geragos, attorney for the girl's family, said he plans to ask the district attorney to press murder or manslaughter charges against Cigna HealthCare in the case. The insurer "maliciously killed her" because it did not want to bear the expense of her transplant and aftercare, Geragos said.

Nataline had been battling leukemia and received a bone marrow transplant from her brother. She developed a complication, however, that caused her liver to fail.

Doctors at UCLA determined she needed a transplant and sent a letter to CIGNA Healthcare on December 11. The Philadelphia-based health insurance company denied payment for the transplant.

On Thursday, about 150 teenagers and nurses protested outside CIGNA's office in Glendale. As the protesters rallied, the company reversed its decision and said it would approve the transplant.

Despite the reversal, CIGNA said in an e-mail statement before she died that there was a lack of medical evidence showing the procedure would work in Nataline's case.

"Our hearts go out to Nataline and her family, as they endure this terrible ordeal," the company said. " ... CIGNA HealthCare has decided to make an exception in this rare and unusual case and we will provide coverage should she proceed with the requested liver transplant."

In their letter, the UCLA doctors said patients in situations similar to Nataline's who undergo transplants have a six-month survival rate of about 65 percent.

District attorney spokeswoman Sandi Gibbons declined to comment on Geragos' planned request for murder or manslaughter charges, saying it would be inappropriate to do so until Geragos submits evidence supporting the request.

Officials with CIGNA could not immediately be reached for comment Thursday night.

[Rot 911]

Yes the HMO was a heartless bastard, but why didn't the parents just tell the hospital to go ahead with the transplant and they would make payments for the next 20 years? Get a loan? Sell the cars? The house? The HMO says no so you just give up?????

[Porsche-O-Phile]

Did they not? I don't know the details of what the parents did/did not do to help their daughter. Not part of the story, but I suppose relevant.

[Jeff Alton]

I agree with wayne, two sides to every story......

At any rate it is very sad when anyone loses a child.

Cheers

[Rick Lee]

Yup, it's very sad. I can't imagine why anyone would hold up a life-saving operation for any non-medical reason. HMO not wanting to pay is not a reason.

[Rick Lee]

A 10% chance of survival is a medical reason and thus legitimate for deciding yea or nay. Assuming the girl would have been fine with a transplant, which is probably never a 100% under the best scenario, and she was at the top of the wait list, then she should have gotten it. If we make hospitals eat their costs for treating illegals and the totally uninsured, I don't think it's asking too much for them to go ahead with the operation on this girl and see if the insur. will pay up later.

[trap]

Sometimes things are black and white. I once (briefly) worked for a large HMO. Driving to work one morning I pulled into the parking lot to see a white van parked in front of the office building. There were a few people lingering around - the van had large, red letters with the words "HMOXXX MADE ME BLIND."

Turns out he needed eye surgery and it was denied. Somehow they not only changed their minds about the denial but the man actually had the surgery that afternoon.

There are many stories involved in working at that company. Some things were good, many others, not so good. I don't think "no" is uncommon for a first pass - justified or not. In this case, though, it may bite them a little bit. Not to mention the sheer tragedy of it all.

But think about it - most of you are parents - can you imagine NOT doing everything possible? While it may not be completely accurate to blame the company, some of you seem awfully quick to cast some doubt on the parents.

[Nathans_Dad]

In my opinion, the hospital and physicians are under a moral and ethical obligation to provide care whether the patient can pay for it or not. I cannot imagine that any hospital would allow a child to die simply because their insurance refused payment for a service. Something else is up here...

[jyl]

Sketchy information, but what caught my eye was:
- She was already severely ill with leukemia.
- Her condition was bad enough that she had a bone marrow operation around Thanksgiving
- Then she developed a complication, deteriorated, and became "vegetative"
- Not sure exactly when the doctors recommended a liver transplant, but it was probably shortly before Dec 11
- She didn't live even 10 days after that
- Was a donor liver even available, that quickly? There are something like 20,000 people waiting for liver transplants, I think. Although I read that donor livers are allocated by severity and urgency of need, so perhaps a critical case can get an organ quickly.
- If she was that ill and deteriorating that quickly, was she even the right candidate for a liver transplant? I read an article that said cancer patients usually do not receive liver transplants, because the immuno-suppressing drugs used for the transplants then make the cancer worse; it is considered "futile".

I think I'd have to know a lot more before blaming the insurer for this.

By the way, I read that liver transplants and the follow-up care usually cost around $200,000.

[Dixie]

The big question is where you draw that line, and I'm sure that this lawsuit will be addressing that issue.

This is the real Pandora's box of Universal Health Care. Provide everyone with every conceivable treatment, regardless of mitigating factors, regardless of costs? Perhaps to contain passing huge costs on to healthy, predominantly young tax payers there should be a limit on when treatment is viable? Who makes those decisions? Can the Government be sued if treatment is denied? And what if an individual has the funds to pay for that denied treatment? Is the care still Universal? Is it fair?

[sammyg2]

Knee-jerk before details or facts, as usual.
I talked about this to a couple I know, who both happen to be practicing physicians. This is basically what they told me:
The girl was dying. She was very sick, and giving her a transplant was nothing more that wishful thinking. At best it would have prolonged the inevitable a little. She was going to die with or without the transplant. When you have leukemia and chemo and your internal organs shut down (as was the case with her, liver, lungs, etc) it is all over.

The insurance coverage clearly spelled out what it would pay for and what it would not. This type of operation was clearly not covered.
Question:
Why didn't the parents OK the operation and agree to pay for it?
Answer, because they knew it was an excersize in futility. The docors had to have told them that. They were grasping at straws but only the ones that someone else had to pay for. Not them. Freaking hypocrites, now they are suing.
I should sue them for not providing that operation to their daughter. They are the ones that denied her that operation, all the HMO did was not agree to pay for it. they never said she couldn't have it, only that someone else would have to foot the boll.
If only they were illegal immigrants they could have gotten all the medical care they wanted for free.

[TerryH]

There are also the anti-rejection drugs necessary for any transplant. Cancer would thrive in that environment.

But still, she was someones daughter. I would give my child every chance possible and hope for the one in a million miracle.

edit: sorry.. this is redundant. see previous post.

[widebody911]

Originally Posted by sammyg2

Why didn't the parents OK the operation and agree to pay for it?
Answer, because they knew it was an excersize in futility. The docors had to have told them that. They were grasping at straws but only the ones that someone else had to pay for. Not them. Freaking hypocrites, now they are suing.

Good point - they should have committed to the operation and then tried to collect from the insurance company afterwards. Sounds like they just want some cash.

[strupgolf]

Widebody, you got it. They want the money, show me the money. The insurance company said it was not covered, case closed. Let the parents pay for it themselves, and make payments like so many others.