Advertisement

Suit Blames Insurance Company Error for Sick Woman’s Death

Times Staff Writer

An ailing Fountain Valley woman died because her insurance company mistakenly told doctors she was covered for liver transplants, then reversed itself just before she was to undergo a potentially life-saving operation, according a lawsuit filed by her family.

As a result of Pacific Mutual Life Insurance Co.'s declaration that Delores Holmes, 50, was not covered under the policy that the Newport Beach firm administered for her employer, officials at UCLA Medical Center canceled the operation, the lawsuit filed in Orange County Superior Court alleges.

But Pacific Mutual, which administers the self-insurance plan for Fountain Valley Regional Hospital and Medical Center, where Holmes worked as a nurse, denies that the error made by its clerk caused Holmes’ death.

“Our actions did nothing to prevent this woman from obtaining a liver transplant,” said Pacific Mutual’s spokesman, Geno Effler.

Advertisement

The lawsuit, filed this week in Santa Ana by Holmes’ husband, son and daughter, says that Holmes was told by doctors at UCLA that she needed a liver transplant in the summer of 1987.

UCLA telephoned Pacific Mutual to confirm that Holmes was covered under an insurance policy. The suit says that a Pacific Mutual employee told the hospital that Holmes was covered.

When a donor became available in December, 1987, the suit says, UCLA again sought to confirm that Holmes’ employer would pay for the operation, which costs, on average, from $160,000 to $260,000.

At this time, the suit says, Pacific Mutual informed UCLA that Holmes’ policy did not cover liver transplants.

Advertisement

“Thus UCLA released (Holmes) from the hospital and she did not receive the required liver transplant,” the suit says.

Holmes sought coverage from Medi-Cal, the suit says. That was approved, but no compatible donor was found before Holmes died on Feb. 15.

The suit contends that had Holmes known in August, 1987, that she was not covered by her insurance plan, she would have had sufficient time to secure Medi-Cal coverage for the operation.

Pacific Mutual contends, however, that it was not informed of Holmes’ peril in December.

Advertisement

“UCLA Medical Center never told us that it had a liver for her or that she was ever scheduled for liver surgery,” Effler said.

He disputed the suit’s assertion that Pacific Mutual was contacted by the hospital just before it decided not to proceed. He said that the firm informed UCLA on Dec. 4--after it had discovered on its own that an error had been made--that Holmes was not covered for the operation after internal audits discovered the error.

A UCLA spokesman, Mike Byrne, refused to say whether Holmes was ever scheduled for an operation.

He did say, however, that the hospital would not have performed the operation if Holmes was not covered by insurance.

Advertisement

“UCLA Medical Center is not state supported,” he said. “Operating revenues are generated from fees for patient care. A patient is placed on the transplant list providing his or her funding is approved,” he said.

Effler explained the company’s initial error by saying that “99%" of the plans administered by Pacific Mutual cover liver transplants but that Holmes’ didn’t cover it.


Advertisement