When Health Insurance Fights Basic Care

Everyone has a story about a time they fought with their health insurance company. Sometimes it is an issue over why a treatment was not covered or a fight about a copay or deductible. Many times, these battles, while incredibly frustrating, cost us little more than some money and time. In other cases, an insurance companies failure to approve or allow necessary medical treatment can cost a lot more. In a recent and tragic case in Los Angeles, it cost a 17-year-old girl her right leg, part of her pelvis and spine. It also cost her insurance company $28,000,000.

On March 26, 2015, The Los Angeles Times reported on the story of Anna Rahm. Anna was member of Kaiser Permanente, a health insurance HMO that uses a managed care approach to member health. Essentially, Kaiser members seek treatment by visiting Kaiser facilities and Kaiser doctors. In March, 2009 Anna visited her local Kaiser facility for severe lower back pain. Despite her healthy appearance (Anna was 5 feet, 4 inches and 125 pounds) doctors diagnosed her as overweight. She was referred to a nutritionist and acupuncture therapist. The pain persisted. Over the next three months, Anna and her mother repeatedly requested an MRI to help diagnose the source of the pain. Despite these requests, Kaiser doctors refused to order any MRI.

Anna’s worst fears were realized when Kaiser finally consented to the test. The MRI showed a large, aggressive tumor in her pelvis. Due to the advanced stage of the tumor, doctors had no choice but to amputate Anna’s right leg, half her pelvis and part of her spine. Anna’s attorney, Mike Bidart argued that if “it were caught earlier, her limb could have been salvaged.” A jury of her peers agreed. After hearing expert testimony from both the plaintiff and the defense, Anna’s symptoms were serious enough to merit the ordering of an MRI. The failure to do so was a violation of the standard of care. On March 25, 2015, the jury awarded Anna $28.2 million for failing to diagnose the tumor. The money will be used to cover her future medical expenses and care associated with the loss of her leg and part of her spine. The verdict will also compensate Anna for her lost earnings as a result of medical malpractice and for her pain and suffering.

It can be very overwhelming fighting with an insurance company to cover tests that can help diagnose an illness. MRIs, CT scans, X-rays and ultrasounds are all expensive imaging tools that are often necessary to diagnose cancers, intracranial hemorrhages, strokes, appendicitis, blood clots and many other serious illnesses. Just because an insurance company may initially deny coverage for these diagnostic tools does not necessarily leave a patient at the end of the road. Patients can always seek a second opinion from another doctor who make a new request directly to the insurance company. Additionally, some insurance companies have independent review panels that allow policyholders to appeal a benefit decision. Finally, Chicago residents can appeal any insurance determination to the Illinois Insurance Commissioner who will review the decision directly with the insurance company.