Page 1 of 3 123 LastLast
Results 1 to 15 of 36

Thread: Family fighting HMO for 4-year-old's life

  1. #1
    Gold Member deckchick's Avatar
    Join Date
    Oct 2005
    Location
    Canadian eh?
    Posts
    832

    Default Family fighting HMO for 4-year-old's life

    I am Canadian, so I don't really get the whole HMO deal, but I read horror stories about HMO's not allowing expensive surgery in cases where the outcome is not 100%.

    Is the true? Do HMO's prefer to let people die instead of paying for long-term illnesses that are expensive?

    from http://sfgate.com/cgi-bin/article.cg.../05/NEVIUS.TMP

    Somewhere in a corporate office at Health Net Inc. is someone who needs to meet Jack Zembsch. Jack is 4, he loves SpongeBob SquarePants, and he is going to die.

    One doctor in the country just might be able to save Jack, but the nation's largest HMO won't let Jack see him because the doctor is not within its network.

    Jack, who lives in Moraga with his parents, Mark and Kim Zembsch, has an extremely rare form of dwarfism called metatropic dysplasia, or MD. It leaves his bones extremely soft, and before long, they'll simply stop growing even as his body continues to get bigger. Eventually, his lungs will be so constricted by his ribs that breathing will become a chore, and an infection could kill him.

    That is, if his spine doesn't simply snap from something as simple as a fall.

    "There is literally only one metatropic kid born in this country each year," Mark Zembsch says. "Jack fits into the category of you-can't-believe-it rare.''

    HMOs never want to hear about rare diseases. And the news that only Dr. William Mackenzie, the nation's acknowledged expert in MD, who works at the Alfred I. duPont Hospital for Children in Delaware, has any chance of saving Jack is unlikely to make them any happier.

    I tried repeatedly to get someone, anyone, at Health Net to comment, but they wouldn't return any of the messages I left on Friday.

    But it doesn't come as any surprise that Health Net would drag its feet.

    "When you have to fly a patient out to the East Coast, it is the fundamental HMO no-no,'' says Jamie Court, a Santa Monica-based health-care advocate and co-author of "Making a Killing,'' a book on the health care system. "It is the M.O. of health care providers to deny access to expensive treatments. They give you the runaround and hope you go away.''

    We all know about that. If we haven't been through it, we know someone who has -- the automated telephone merry-go-round, the paperwork snowstorm, the mind-boggling protocols that must be followed to the letter. With weary resignation, we fight and complain and yell until -- grudgingly -- the insurance company pays up.

    But, see, this is different. This is a 4-year-old boy. And if he can't have a series of difficult and touchy operations -- by the only doctor in the entire country with the expertise to perform them -- his spine will bend his body until it either crushes his lungs or snaps.

    Jack is just a few degrees from that point now.

    His parents have told the story several times, but it isn't just another long, sad tale of how health care is screwed up in this country. Mark Zembsch gets most of the way through it, but his voice tends to get hoarse, and he's prone to running his hand through his hair and looking away.

    "You just keep thinking that you are going to wake up and it is all resolved,'' he says. "It is so clearly the right path for Jack. I keep thinking I am going to get the letter from some guy saying, 'Sorry, he fell through the cracks. We will get this done.' ''

    That isn't going to happen. It didn't happen when the Zembschs' primary-care physician, Dr. Jane Hunter at Alta Bates Medical Center in Berkeley, wrote a note to Health Net saying "it is imperative'' that Jack see Mackenzie.

    It didn't happen when Health Net sent Jack to the highly regarded UCSF medical center to be treated by Dr. Mohammad Diab, a surgeon who is in charge of pediatric orthopedics. Diab told the family he essentially had no experience with the surgery Jack needs and wrote to Health Net that Jack should see Mackenzie immediately.

    "The door is closing, if not closed,'' Diab wrote.

    It doesn't get any plainer than that. Jack needs an operation. He will die without it.

    "I thought it was a no-brainer at that point,'' says Arnold Levinson, a San Francisco health care insurance attorney.

    Apparently not. In all there were four appeals. Some were filed twice. In every case, Health Net took the entire 30 days allowed by law to respond, then came up with another rejection or roadblock. Finally, on Oct. 12, Health Net ruled that Jack should go back to Diab.

    So after eight months of appeals, pleas and medical forms, the Zembsch family had gone in a big, pointless circle.

    It was maddening. But that isn't what keeps Kim Zembsch up at night.

    "Dr. Mackenzie said he could be walking one day and fall on his bottom,'' she says, "and his spine could snap, just like that.''

    Instead of being beaten down by this runaround, they decided to step up.

    They contacted Levinson, who is not to be trifled with. In 2003, he won the tenth-largest verdict in California history, $32 million, in a disability insurance case. That might get Health Net's attention.

    The lawsuit will be filed Monday.

    You want a fight, Health Net? Better suit up. Jack's coming after you

  2. #2
    Friend of Gossip Rocks! buttmunch's Avatar
    Join Date
    Oct 2005
    Location
    Uranus
    Posts
    31,885

    Default Re: Family fighting HMO for 4-year-old's life

    God, HMO's suck. You'd think this country would finally get around to some sort of proper, easily accessable healthcare (although socialized healthcare isn't working very well in other parts of the world, either). That being said, can't this super-duper doc get his ass on a plane and go to the kid? Let's all write letters to both the HMO and the doc and see what happens then.
    'Those who sacrifice liberty for security deserve neither.' Ben Franklin

    "When fascism comes to America, it will be wrapped in the flag and carrying the cross."
    --Sinclair Lewis

  3. #3
    Silver Member Morrisonlver's Avatar
    Join Date
    Oct 2005
    Location
    The Psych Ward
    Posts
    457

    Default Re: Family fighting HMO for 4-year-old's life

    I worked in a doctor's office and had to deal with these assholes on a daily basis. I can't even count how many time the MD I worked with sat on the phone and yelled at these people for not having a heart. Even after he explained why the Pt need such and such procedure, they still wouldn't agree to cover it most of the time. HMO's are worthless.

  4. #4
    Gold Member deckchick's Avatar
    Join Date
    Oct 2005
    Location
    Canadian eh?
    Posts
    832

    Default Re: Family fighting HMO for 4-year-old's life

    Again, please excuse my ignorance on the U.S. medical system. Please answer my following questions.

    1. Are HMO's are the standard for insurance companies?

    2. How prevalent if the dis-allowing medical treatment for high-risk/probable death outcome?

    3. Is this really the only choice for most Americans?

    I am Canadian, so I have universal health care. Yes we do have long waiting lists for specialized care, and yes some people have died waiting for care. But I have never heard of any Canadians being refused care.

    So just how bad is the American health system?

  5. #5
    Hit By Ban Bus! AliceInWonderland's Avatar
    Join Date
    Oct 2005
    Location
    you already know.
    Posts
    44,442

    Default Re: Family fighting HMO for 4-year-old's life

    I fucking hate Insurance companies, there's no need for them since they hardly ever pay up for anything: car, health, home - they suck every last motherfuckerin one and I know there's a hell for industries like this!

  6. #6
    Hit By Ban Bus! DisruptiveHair's Avatar
    Join Date
    Oct 2005
    Location
    UK, soon to be home in the USA
    Posts
    1,338

    Default Re: Family fighting HMO for 4-year-old's life

    The same thing'd probably be happening with the NHS.

  7. #7
    Hit By Ban Bus! DisruptiveHair's Avatar
    Join Date
    Oct 2005
    Location
    UK, soon to be home in the USA
    Posts
    1,338

    Default Re: Family fighting HMO for 4-year-old's life

    Quote Originally Posted by Frank_Rizzo View Post
    1) HMO's aren't the standard but they are very common.

    2) I honestly don't know the answer to that. I've heard a few stories similar to this but I really don't know how common it is.

    3) As Americans, we don't have a choice. Our employer picks the company and picks the plan and it's either: take the insurance or have none. We have high deductibles, outrageous out of pocket expenses, high copays and also a coinsurance. It's crazy. There are good plans out there, but you get what you pay for and most employers go the cheapest route possible.

    The American healthcare system is DISGUSTING. It makes me sick. People over 65 are eligible for Medicare, but even that only pays 80% of the allowable amount, so if you have an expensive treatment... say chemotherapy, surgery, etc... you're stuck paying 20% of that unless you have a secondary.
    Hey...if you think it's bad in America, come live here for 4.5 years and experience the bag of SHIT that is the NHS. You will be thanking your lucky stars that you live in America. I guarantee it.

  8. #8
    Friend of Gossip Rocks! buttmunch's Avatar
    Join Date
    Oct 2005
    Location
    Uranus
    Posts
    31,885

    Default Re: Family fighting HMO for 4-year-old's life

    Well, at least where you are there is a choice. You can go private if you can afford it.
    'Those who sacrifice liberty for security deserve neither.' Ben Franklin

    "When fascism comes to America, it will be wrapped in the flag and carrying the cross."
    --Sinclair Lewis

  9. #9
    Hit By Ban Bus! pacific breeze's Avatar
    Join Date
    Oct 2005
    Location
    in the wild blue yonder
    Posts
    15,479

    Default Re: Family fighting HMO for 4-year-old's life

    ^^ That is the kind of story that sends chills up my spine. How could universal health care be worse that that? Sure, there are problems with it, but nobody would ever be stuck with a bill like that in Canada. That's insane.

  10. #10
    Hit By Ban Bus! pacific breeze's Avatar
    Join Date
    Oct 2005
    Location
    in the wild blue yonder
    Posts
    15,479

    Default Re: Family fighting HMO for 4-year-old's life

    ^^ Frank, I wasn't implying that universal health care is worse than having no insurance. I was riffing on what DH said. Your poor brother....

  11. #11
    Gold Member moocow's Avatar
    Join Date
    Oct 2005
    Posts
    717

    Default Re: Family fighting HMO for 4-year-old's life

    Quote Originally Posted by Frank_Rizzo View Post

    3) As Americans, we don't have a choice. Our employer picks the company and picks the plan and it's either: take the insurance or have none. We have high deductibles, outrageous out of pocket expenses, high copays and also a coinsurance. It's crazy. There are good plans out there, but you get what you pay for and most employers go the cheapest route possible.
    I thought that way, myself. But I was given some information and a contact number for someone from Mid-West (a company in Tennessee). I signed my daughter up for health insurance for about $200 less per month than I was paying for her premiums through my company's provider. There is a bit of give and take - the number of covered visits per quarter, but then there's a negotiated rate that you'd at most have to pay, things like that.

    As for this case, it is dis-heartening. Hopefully with enough national interest, this family can get some donations and/or reduced prices or waived rates.

    In any case that you're stuck with a huge bill, whether you have insurance or not, try negotiating with the provider. Sometimes, you'll get a discount if you pay cash, which makes it cheaper if you get a loan and pay it off. Or they'll accept payments themselves, etc. I've known of cases where providers have waived the uncovered portion when requested.

  12. #12
    SVZ
    SVZ is offline
    Do fish have boogers? SVZ's Avatar
    Join Date
    Oct 2005
    Location
    Venus
    Posts
    1,000,003,609

    Default Re: Family fighting HMO for 4-year-old's life

    As for this case, it is dis-heartening. Hopefully with enough national interest, this family can get some donations and/or reduced prices or waived rates.
    Isn't that kind of a failure, when health care has to be provided through donations or publicity?

  13. #13
    Gold Member moocow's Avatar
    Join Date
    Oct 2005
    Posts
    717

    Default Re: Family fighting HMO for 4-year-old's life

    Quote Originally Posted by SVZ View Post
    Isn't that kind of a failure, when health care has to be provided through donations or publicity?
    My grandfather died when my dad was 12 for very similar reasons. I don't think they even had health insurance back then, and the only hope for him was a procedure that was only being done by one doctor at the time. The cost was in the $10,000+ range in the late 40s. He didn't get the operation. 10 years later, the operation was commonplace. It was to repair a valve in his heart damaged by rheumatic fever. Oh and to top it off, the company that he'd been paying for years for life insurance screwed the family over by not paying out.

    So it seems we haven't changed much in the past 50+ years

    It is deplorable that donations have to cover it, but if it was my child, I'd be begging for them.

  14. #14
    Gold Member deckchick's Avatar
    Join Date
    Oct 2005
    Location
    Canadian eh?
    Posts
    832

    Default Re: Family fighting HMO for 4-year-old's life

    Quote Originally Posted by Frank_Rizzo View Post
    There is no possible way universal healthcare is *worse* than no healthcare at all. Something is better than nothing. My brother is 28 and he'll be paying off that 17 grand for at least 10 years. And the thing that gets me is they did NOTHING. $17,000 for the courtesy of an uncomfortable hospital bed, some blood tests and shitty hospital food..


    Thats beyond brutal. How can they justify charging that?

    Quote Originally Posted by Frank_Rizzo View Post
    I work for an oncologist and we don't see patients without insurance and we don't give chemo to patients without Medicare AND a secondary. So these people are refused treatment for cancer because of the state of healthcare. It's sickening.


    Thats the kind of thing that just astounds me. America is supposed to be the Compassionate Superpower that helps other nations.

    How can you as Americans even stand to read that kind of stuff? Do you truly let people die just because they have no insurance?

    That just is something I cannot understand. Billions and billions spent on both war and foreign aid while your own citizens die.......
    Vegetarian - Old Indian word for "Bad Hunter"

  15. #15
    A*O
    A*O is offline
    Friend of Gossip Rocks! A*O's Avatar
    Join Date
    Oct 2005
    Location
    Being Paula
    Posts
    30,395

    Default Re: Family fighting HMO for 4-year-old's life

    Quote Originally Posted by disruptivehair View Post
    Hey...if you think it's bad in America, come live here for 4.5 years and experience the bag of SHIT that is the NHS. You will be thanking your lucky stars that you live in America. I guarantee it.
    At least it's a FREE bag of shit DH. Considering the NHS supports over 60million people who all expect treatment NOW I think it does pretty well. And I can tell you that in emergencies, urgent surgical situations, maternity and obstetric care the NHS does an excellent job in the circumstances. I assume you will be getting private medical insurance in the US? Nothing to stop you doing the same in the UK.
    I've never liked lesbianism - it leaves a bad taste in my mouth
    Dame Edna Everage

    Just because you're offended doesn't mean you're right.

Page 1 of 3 123 LastLast

Thread Information

Users Browsing this Thread

There are currently 1 users browsing this thread. (0 members and 1 guests)

Similar Threads

  1. Replies: 11
    Last Post: October 2nd, 2006, 05:28 PM
  2. Tom Cruise fighting for TomCruise.com
    By MaryJane in forum Gossip Archive
    Replies: 13
    Last Post: May 15th, 2006, 02:39 AM
  3. They're fighting for our freedom!
    By Grimmlok in forum U.S. Politics and Issues
    Replies: 4
    Last Post: January 14th, 2006, 09:08 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •