‘Patient Error’ and HMO Responsibility

Question: For the last year my husband and I have been under terrible financial pressure because of what I feel was a breach of faith on the part of our HMO (health maintenance organization). I was pregnant last July after having had our 6-year-old son and 4-year-old daughter by Caesarean section. I didn’t want to go through this again--I wanted to experience natural labor and birth--and had read extensively about VBAC (vaginal birth after Caesarean). A midwife examined my X-rays, measured me and assured me that a vaginal birth was possible even though I was carrying twins.

The HMO (General Medical Health Center in Anaheim) sent me to Brotman Medical Center, its approved hospital in Culver City, where I was told that this was impossible and that a Caesarean section was the only way to deliver. I didn’t believe them and went home. I began experiencing labor and for a couple of days got progressively worse until it was clearly an emergency situation. We called the paramedics, who told me that they could only take me to the nearest hospital, Daniel Freeman Memorial, just a couple of blocks away in Inglewood, and that I would then have to arrange for a transfer by private ambulance.

I don’t remember now whether it was from our home when we realized I was in trouble, or whether it was from Freeman. My husband called the HMO emergency number where, supposedly, a doctor was on duty 24 hours a day, seven days a week, who could OK my admittance to a non-approved hospital or offer other alternatives. It was the Fourth of July, however, and my husband was told by someone that they could neither approve nor deny the admittance because it was a holiday, and nobody in authority was available.

We arranged for an ambulance to take me to Brotman, but as they were putting me on a gurney I began bleeding profusely, and the hospital people refused to let me be moved. My babies, one with a congenital deformity, were delivered by Caesarean. The next day my husband called the HMO and asked approval to have us moved to Brotman.

He was told “no way,” that, since I had tried to be so smart because I thought I could have a vaginal delivery, it was all my responsibility. They refused the claim except for $5,000 of the $25,000 total, which they paid to Brotman for things like a sonic scan and other care before labor. We asked for and got a medical review, and the claim was refused again.

The attitude was: “Who do you think you are to challenge a doctor’s opinion?” They wouldn’t pay for my or the twins’ expenses. I asked them then that if one of the twins developed some sort of health problem--like a bad cold--that was completely unrelated to their birth and if I took them to an approved facility, would they pay for that? And I was told that, no, they wouldn’t.

I have also been told that our only recourse is to submit it to arbitration, but that we would have to hire a lawyer to represent us and that the arbitrator’s fee would have to be paid by us too--at a total estimated cost of $5,000.

It seems to me that if General Medical agrees to cover emergency costs in a non-approved hospital (as was, and is, our understanding of the contract), then they should cover it even though, I admit, I was wrong and they were right. Did my being wrong change this to a non-emergency situation, even though the people at Freeman said it would be “murder” to move me in my condition?

And why is General Medical continuing to refuse to pay for my babies’ care for things that are completely unrelated to their birth? Why should they suffer for my mistake?--S.G.

Answer: As the medical director of one HMO put it: “That’s a touchy one that gets into all sorts of philosophical areas having to do with how HMOs, of necessity, have to enforce rules in order to run a program efficiently.”

Insisting on anonymity and insisting he not be told the name of the HMO involved in this matter, the doctor pondered why his competing HMO here seemed to refuse to discuss the possibility of vaginal birth with you.

“She certainly had the right to explore the possibilities of natural birth because it’s quite true today that the old saw, ‘Once a C-section, always a C-section,’ is out the window. The College of Obstetrics is on record as saying natural birth after one or more Caesarean deliveries is a distinct possibility and that there is nothing wrong with trying it as long as the delivery room is set up for a Caesarean in case it doesn’t work. So, it was an error not to discuss it more fully with her--if, of course, that was, indeed, the case.”

Everyone contacted in connection with your letter--including spokesmen for both the county and state medical associations as well as your HMO, General Medical Health Center--is in agreement with your own admission that it was an error on your part to put as much faith as you did in the midwife’s assurance that you could, indeed, experience a natural, vaginal birth. There’s also general agreement that a broader and more philosophical question has been raised here:

Patient error or not, does a mistake on the part of an HMO member (in your case, putting too much confidence in the opinion of a non-medical individual on a strictly medical question) make any subsequent emergency arising from that mistake a non-emergency? If you extend this hypothetically, could an HMO refuse to pay for emergency medical treatment at a non-HMO hospital for one of its members if that member had been critically injured in an automobile accident that was clearly his fault?

And again the unanimous answer is: No, although General Medical points out that a review of your case is necessary before such a broad comparison can be drawn.

As the doctor representing the other HMO put it: “An HMO works on the premise that duplication of services increases costs and that a member is well cared for as long as he or she stays within the system. But if he goes out of the plan--for whatever reason--he’s on his own. An emergency, though, is strictly another matter, and ‘fault’ has nothing to do with it. If it’s a medical emergency, the HMO will cover the costs, regardless of who takes care of you. If you’re in deep trouble, you simply go to the nearest facility and we’ll transfer you later.”

Under state law, according to Michael Zabloski, an attorney here with the Department of Corporations--which licenses most HMOs in the state under its division of health and human services--”Section 13345 of the Health and Safety Code requires that the HMO must specify, in detail, its basic health-care services. And under this, each consumer must be supplied with a copy of its ‘Evidence of Coverage’ form. This is where, in detail, it must be spelled out what is meant by ‘emergency.’ And this is purely a medical question, not one of fault.”

By a very wide margin, Zabloski adds, the majority of consumer complaints filed with the department’s man in charge of such matters, Jerry Todd, have to do with disputes over what is or is not a true ‘emergency,’ not the circumstances creating it.

But in your case, there is, again, unanimity among those contacted that the sort of hemorrhaging you experienced after the paramedics took you to Freeman--and you were in the process of being transferred to Brotman--was indisputably a medical emergency, and the people at Freeman were 100% right in refusing to let you be moved.

The key question then is not whether your situation was a true medical emergency--which it certainly was--but whether there was a doctor on duty at the HMO’s emergency telephone number when your husband and the hospital administration called for emergency clearance.

And what does Anaheim’s General Medical Health Center, your HMO, have to say specifically about all this?

When first contacted, Davina Lane, the HMO’s senior vice president of marketing and communications, said “We are digging it out and are researching it--it’s never really been a closed case, you know--and we’ll certainly be in touch with Mrs. G. about it. It’s obviously an extremely complicated case, and we want to look into all angles of it. We quite agree with you, up front, that ‘emergency’ doesn’t really have anything to do with whether she was at fault or not. Naturally, because of the confidentiality of the medical questions surrounding all this, we can’t discuss that aspect of it with you. But, as far as the other questions raised--about the emergency telephone number, not transferring her and that sort of thing--we’ll certainly look into it all and keep both you and her informed.”

Subsequently, here is the letter received from General Medical Health Center and reprinted with Mrs. G’s permission:

Dear Mr. . . .

We have reviewed the circumstances of your wife’s delivery of twins at Daniel Freeman Memorial Hospital, July 4, 1984. Based on that review, we have decided to cover the delivery and post-natal care of the children at Daniel Freeman.

Please arrange for the hospital and attending physicians to submit their billing for their treatment to our Claims Dept. for processing. We presume that this decision renders your other questions and requests of your letter of May 29, 1985, received by us on June 21, 1985, academic.

If such is not the case, please advise. Thank your for your patience in resolving this claim.

Sincerely,

Michael E. Henry

President and Chief Executive Officer