Dispute Over Health Care Simmering
Question: From February until June of this year I had occasion to utilize the services of Family Health Program (FHP), a health maintenance organization headquartered in Long Beach.
In April, I became aware of a health condition for which I immediately sought treatment from FHP. After having been seen by a primary-care physician in FHP’s Santa Ana office from then until June, and also having the services of an eye, nose and throat specialist in their Fountain Valley office, I still had the same basic condition.
I was becoming increasingly alarmed by the long-term problem and I chose to see a private physician for evaluation and treatment. I was diagnosed as having three separate illnesses. Based upon lab testing that was performed, I was prescribed medications to resolve the acute illnesses.
I chose to file a complaint with FHP based upon what I consider to be insufficient care and treatment. I personally went to the Santa Ana clinic office, spoke with an FHP representative and substantiated my complaint with copies of a signed diagnosis by the private physician I had consulted.
As of this date, there has been no resolution of the problems that I brought to the attention of FHP. There has never been a formal hearing responding to the matters I brought up.
Since FHP did not respond in a timely fashion to the complaint I had initiated with them, I also filed complaints with the Department of Corporations, State Board of Medical Quality Assurance, state attorney general’s office and the office of Sen. Edward R. Royce (R-Anaheim). I have been informed by the Board of Medical Quality Assurance that they chose not to investigate . . . the Department of Corporations tells me they will take the complaint into consideration in three to five years when they audit the health plan . . . Sen. Royce’s office will not attempt to intervene in matters of medical expertise but did attempt to question FHP’s policy of billing . . . .
The financial liability for which I am responsible is now a considerable amount since I have had to seek medical care from three separate physicians and have been hospitalized for surgery.
I am shocked and amazed that there appears to be such deficient remedy to address the complaints I filed re: FHP.--Mrs. K.A.D.
Answer: No one, certainly, can fault you on either your persistence or on your procedural approach--you filed all of your complaints to all of the right people.
“Quality of care,” which is what we’re talking about here, is a mushy area whenever we get into professional services--medical, dental, legal or what-have-you--and it would be essentially the same frustrating situation for you if it had involved a private hospital and private physicians instead of a health maintenance organization.
With your permission, we sent along a copy of your letter to Family Health Program, and here is that organization’s response:
“Three levels of medical review staff--including FHP’s Orange County medical director, as well as the physician who oversees the activities of all the area medical chiefs--reviewed the complaint.
“The physicians, in each case, felt there was ‘no quality of care problem.’
“In fact, Mrs. D. saw FHP physicians on four separate occasions between March 4 and May 15, and was given medication appropriate to her diagnosis each visit.
“Her personal decision to seek a second opinion, in FHP’s opinion, could be considered possible over-treatment.
“FHP is satisfied that--in spite of Mrs. D’s longstanding complaints--it has provided her the best possible medical care. Due to confidentiality considerations, FHP is not able to discuss the specifics of her case in detail.
MARK ELLIOT JONES
account supervisor”
In our subsequent telephone conversation about the response from FHP, which I, but not you, received, you informed me that this was the first indication you had had that a review of your complaints had been conducted by anyone. And, not unnaturally, you took exception to FHP’s definition of the phrase “medication appropriate to her diagnosis.”
“I was never given any lab tests at all, and the ‘appropriate’ medication was simply penicillin. I had to go to a private physician to have a culture taken.”
Nevertheless, that’s where the situation--and your barrage of complaints--rests at the moment.
Q: I was interested in your recent column on earthquake insurance. I have such insurance. However it is with United States Automobile Assn., an insurance company located in San Antonio, Tex. Will I have the same degree of protection I would have with a California company?--R.M.L.
A: No problem, according to John McCann, regional vice president of the Insurance Information Institute in San Francisco.
It doesn’t make any difference where the property/casualty insurance company is domiciled. If it writes earthquake insurance in California, it is automatically under the control of the California Insurance Guarantee Assn. (CIGA), and if its earthquake-damage losses (heaven forbid!) should threaten its solvency, all other companies writing similar insurance here would be proportionately assessed to cover those losses (up to a maximum of $500,000 per claim).
Your company, USAA, as a matter of fact, is the seventh largest writer of homeowner policies in California--under which earthquake coverage falls. Just as the earthquake insurance that USAA provides you is covered by CIGA, so are such other biggies as State Farm (headquartered in Bloomington, Ill.), Allstate (out of Chicago) and Safeco (out of Seattle).
Don G. Campbell cannot answer mail personally but will respond in this column to consumer questions of general interest.