Woman Sues Her HMO for Not Covering Maternity Costs : Insurance: Health Net refuses to pay because the Moreno Valley teacher gave birth at the organization’s Oceanside facility.

A Moreno Valley schoolteacher has sued Health Net, the state’s second-largest health maintenance organization, for refusing to pay her maternity bills because she delivered her baby at a Health Net facility in Oceanside instead of at her “home” facility in Riverside.

First-time mother Sara Israel said she was stunned when Health Net rejected her $5,000 medical claim, citing a policy that forbids women in their ninth month of pregnancy to travel more than 30 miles from their home clinic.

“It is ludicrous that they’d put a 30-mile leash on a woman,” Israel, 33, said Friday.

Her lawyer, Claremont-based William Shernoff, contends that this and similar restrictions, which he said are becoming increasingly frequent among HMOs, are adopted in the name of cost savings to consumers but are in fact mainly meant to increase profits.

There is an element of sexism in the policy as well, Shernoff charged, since Health Net does not restrict a man who has heart disease and risks a sudden heart attack from traveling 30 miles away from his doctors.

Health Net, with 1.25 million members in California, says its policy is firmly grounded in concern for the health of both mother and child. “The medical consensus says women should not travel in the last month of pregnancy,” a spokesman for the Woodland Hills-based company said Friday.

He branded as “absolute, utter nonsense” Shernoff’s contention that the policy is meant to boost Health Net’s profits.

In her lawsuit complaint, filed in Riverside Superior Court, Israel said she and her husband took an 80-mile vacation trip to Oceanside last April during spring break from her Moreno Valley elementary school, where she teaches second- and third-graders.

On April 12, just before leaving, she visited her obstetrician, who told her that her cervix was not dilated and the delivery did not appear imminent, according to the complaint. The doctor scheduled another visit for April 20, two days before Israel’s April 22 due date.

But at 2 a.m. on April 17, the complaint continues, Israel awoke in labor with contractions so frequent and strong that she and her husband decided it would be dangerous to try to drive to the Riverside Medical Clinic, their home Health Net facility. Instead, they called an ambulance and instructed the driver to take Israel to Tri-City Medical Center, the Health Net facility in Oceanside.

At 4:08 a.m., barely two hours after beginning labor, Israel delivered a 7-pound, 13-ounce baby boy, William Travis.

Twelve days later, Israel got a letter from Health Net informing her that it was denying her claim for coverage of the delivery, hospital stay and ambulance ride. The letter said that normal deliveries in the last month of pregnancy are not considered emergency care and are not covered except at the member’s home facility.

Israel said she was completely unaware of the restriction despite having attended Health Net’s prenatal classes and having had frequent office visits with her Health Net obstetrician. Shernoff contends that the restrictive language is “buried” in her insurance contract and is not contained in the pregnancy benefits section.

“Health Net’s policy keeps a pregnant woman under virtual house arrest,” the complaint states, adding that the restriction “could force many gainfully employed women to lose their jobs” if they commute more than 30 miles.

“This was a discretionary pleasure trip and she was five days from her due date,” the Health Net spokesman said. As for the policy threatening women’s employment, he said: “If you’re that close to your due date, you should be on maternity leave.”

The spokesman said that similar policies are widespread if not universal among California HMOs.

However, CareAmerica Health Plans, a Chatsworth-based HMO with 225,000 members, will cover deliveries at any of its network facilities in seven Southern California counties, a spokeswoman said Friday.

Carol Jimenez, a staff attorney for the nonprofit Center for Health Care Rights in Los Angeles, said the policy seems to conflict with the way that HMOs like Health Net tend to market themselves to the public.

“HMOs advertise and get members by saying, ‘We have all these providers in our network and give you all these choices,’ ” she said. “But when it comes down to it, with this policy they’re saying, ‘No, you don’t have a choice. You can only go to one place.’ ”

Shernoff said the lawsuit seeks payment of Israel’s medical bills, compensation for the emotional distress that the incident has caused her and her husband, plus punitive damages to discourage Health Net or other HMOs from such practices. He is also seeking an injunction to suspend the policy immediately.