Here is a case of an HMO simply abusing the process to the complete disregard of the health of the patient.

Little Jack Zembsch suffers from a very rare form of dwarfism that will likely kill him without treatment available only one place in the country.

But the doctor isn't in network.

So the family HMO, Health Net, has taken a series of steps that amount to a directive to let Jack die.

"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 everyone, including the doctor that Health Net wants treating Jack, are on the same page -- only Dr. Mackenzie has the expertise to treat Jack. But Health Net does not care. Better one child should die for the good of the shareholders. than the bottom line be impacted negatively.

But a lawsuit is coming -- Monday.

As the spouse of a chronically ill patient, I hope that Health Net gets crushed.

Posted by: Greg at 12:52 PM | Comments (4) | Add Comment
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