Insurance Information

IMPORTANT: For TIPS on how to deal with your health insurance carrier, see below.

Insurer is Sued Over Ads for HMO

Aetna US Healthcare says it cares for clients' health. A California group says the company cares for profit.

Summary of a Philadelphia Inquirer article, April 20, 1999, written by Karl Stark

On April 19, 1999, a California consumer group filed suit against Aetna US Healthcare. The Foundation for Taxpayer and Consumer Rights is a nonprofit advocacy group in Santa Monica, California. It alleges the giant HMO systematically misleads patients by stating in ads that members' health is its first priority. It is alleged in the suit that Aetna's real goal is to generate shareholder returns. The suit also alleges that Aetna uses financial incentives to reward doctors who give less care.

"In crucial areas, what Aetna's all about is making money," said Ed Howard, senior counsel for the consumer group. "Aetna has embarked upon a campaign to eliminate the ability of doctors to have any kind of meaningful say in how medical care is provided."

The group says its suit against Aetna is the first federal racketeering suit to be filed against an HMO since the US Supreme Court ruled that consumers could sue insurers under the RICO (Racketeer Influenced and Corrupt Organizations) Act. The ruling came down in January of this year.   If successful, a suit won under the RICO Act could bring triple the amount of damages.

The consumer group's suit closely follows similar charges made by the American Medical Association against Aetna in the past 2 years.

Basically, the suit alleges false advertising. Many of Aetna's advertisements are quoted in which it states that its main goal is improving and maintaining the health of its members. The suit says that Aetna is more interested in cutting medical costs. It is charged that doctors who sign contracts with Aetna are paid more if they have over 750 patients; that doctors receive incentives when patients do not use emergency rooms and hospitals; and that secret contracts between Aetna and its doctors hurt patient care.

Also, because HMOs cannot be sued by members of plans regulated under the federal Employee Retirement Income Security Act, ERISA, Aetna encourages its doctors to give more treatment to members of non-ERISA plans.

Aetna spokeswoman Jill Griffiths declined comment on the suit because company officials had not yet seen it.

Jury Returns Record Award Against HMO

Summary of a Los Angeles Times article, Thursday, January 21, 1999, written by Julie Marquis

After a 2-month-long trial, a San Bernadino jury has awarded a widow $116 million in punitive damages to be paid by Aetna US Health Care of California. Schoolteacher Teresa Goodrich also won $4.5 million in damages for medical expenses and loss of companionship. The punitive award stemming from the jury’s finding of "malice, oppression and fraud" brings the total of the verdict to over $120 million.

The verdict was described as a clear signal of the public’s anger at HMOs. After reporting the verdict, several jurors were in tears. Juror Maria Almirol said "Justice was done. We just did what we thought was right. We all wanted to send a message that everybody deserves to be treated fairly, especially when they are sick."

Although David Goodrich fought furiously until his death, he died thinking he left his wife with enormous medical bills because Aetna refused to cover his experimental cancer treatment. Aetna’s attorneys faulted the 44-year-old deputy district attorney for seeking medical treatment outside the Aetna plan without first getting Aetna’s approval. However, Aetna’s attorneys admitted their network doctors were "inexperienced" with Goodrich’s rare type of stomach cancer. Goodrich’s own doctors agreed that he should be treated outside the Aetna network.

During the trial, the Goodrich’s lawyer, Michael J. Bidart, argued that Aetna had delayed and denied approval for 2.5 years. Bidart said that "When David Goodrich finally did receive treatment, Aetna refused to pay for it." After the trial, Bidart said "People are just turned off... The HMOs are corporate executives practicing medicine where profit is the motive, not the best interests of the patient."

Because of a federal law governing employee benefits, nearly 125 million Americans with employer-based health insurance are largely precluded from recovering punitive damages from their insurers, ie, damages from denial of treatment resulting in death, injury, or economic loss. The law known as ERISA, the Employee Retirement Income Security Act, allows recovery of only the value of the benefits they were entitled to. Because the potential awards are not sufficient to justify the high expense of a lawsuit, many patients cannot find a lawyer willing to take their case.

However, ERISA does not apply to government employees or those who buy insurance directly, that is, not through their employer. ERISA did not apply to David Goodrich because he worked for San Bernardino County. Therefore, Teresa Goodrich was able to sue for punitive damages, and thus was able to hold Aetna legally accountable for its actions.

Aetna states that it had acted fairly in this case. However, Aetna said that it has implemented some new policies since the Goodrich case that will allow all its HMO members to have access to an external review. The external review is a procedure in which an independent physician reviews the case in question.

Today, most people cannot sue their health insurance company. However, federal legislation is pending in an attempt to create a level playing field for all health care consumers.

Health Insurance Tips

Insurance companies have paid for antineoplaston therapy in the past. However, if your insurance carrier is not inclined to do so, here are some tips:

[These tips are meant to serve as a general guide only. In no way is it implied or asserted that following these tips will ensure that your insurance company will pay for antineoplaston therapy.]

It is a good idea to keep in mind that your insurance company may turn out to be your adversary and not your partner in your disease. In other words, look out for your own interests.
Know your rights.
Obtain a copy of your contract. A lot depends on the wording, or language, of the contract. If you decide to contact a lawyer, you will need it.
It may be worthwhile to have an experienced lawyer read over the contract and give you advice, because a lot depends on the language of your contract.
Read the contract yourself and follow the letter of the contract in your dealings with the insurance company. You will find that the insurance carrier may feel it does not have to abide by the contract, but you must. Yes, it is unfair.
When reading the contract, look for legitimate arguments and get the facts to back them up.
You may want to look at the many books available today about health care insurance carriers. Be sure to check the year the book was published before buying.
Do some research into your insurance company. This is very important. Today, many companies are merging and being taken over by other companies. For example, in eastern Pennsylvania, Independence Blue Cross and Pennsylvania Blue Shield completed a transaction that transfers ownership of Keystone Health Plan East and full operation of Personal Choice and Blue Choice health plans to Independence Blue Cross. This may sound complicated, and it is. This example is provided because, as you can see, how would you ever know that all these companies are interrelated if you did not look into the matter?  Most of the time, this information is not made public. Certainly, it will not be easily accessible because your insurance carrier may not want you to know who really is calling the shots. It may take some digging to find out where your health insurance carrier is in the structure of the subsidiaries and parent companies. You can begin on the Internet by checking out the website of your state's Department of Health. Search under, for example, "Department of Health" + "California". In the least, you can obtain a phone number so that you can begin asking questions. It may even take a trip to your state's capitol to discover what is really going on.
You will need persistence, and you will need to keep yourself organized.
You may want to enlist the help of support groups, advocacy organizations, politicians, and your employer (or whomever provides your health care insurance) in your efforts.
Put everything in writing, get everything in writing, and document everything. Doing these things makes more work for you when you need it the least, but it may be worthwhile in the long run.
Demand that you be given in writing the reasons for denial of any treatments or procedures and which treatment or procedure was denied. Doing so will ensure that you will obtain the name of a actual person at your insurance company that was involved in the denial. It will also ensure that there is no misunderstanding in the future about what was denied, by whom, and when.
Also keep notes on every phone conversation you have that pertains to your complaints.
Ask your insurance carrier for the name of the person who will be your liaison, a person you will need to contact with questions, etc. But, never take that person's word for anything -- Get everything in writing.
Don't throw away anything relating to insurance.
Keep everything relating to your claims.
Demand that your insurance carrier provide you with definitions of the terms experimental, investigative, medical necessity, and so on.
If your complaint is denied, follow the appeals process.
Demand the name and credentials of the person who denied your claim. Mention that you need to know who will take responsibility if your safety or life is jeopardized. (You probably won't receive the name and credentials; however, you are letting the insurance company know you mean business.)
Show that antineoplaston treatment is cheaper than traditional therapies and their potentially serious and sometimes fatal short- and long-term side effects.
Follow the rules for appeals exactly. Sometimes the rules for appeals are in the contract. If they are not, then write to your insurance company to request them.
Ask your insurance carrier for the documents it used to make its decision.
Make sure that the insurance carrier complies with its own rules, which often is not the case.
Request payment for "routine" services. In writing, tell your insurance carrier that the Burzynski Clinic requests payment of benefits only for routine professional services, supplies, and equipment required to treat any patient with advanced cancer with any type of chemotherapeutic agent.
Find out if your insurance carrier has paid for antineoplaston therapy previously, in your state or in other states.
Find out if your insurance company is paying for other clinical trials.
Find out if your insurance company pays for chemotherapy supplies, for example, tubing, bags, and pharmacy charges to mix drugs.
Use the Internet. You can obtain a great deal of information on the Internet: information about your insurance carrier, about lawyers who handle insurance cases exclusively, about clinical trials your insurance carrier may be paying for, and more.
Look up Managed Care Magazine on the Internet, the April 1997 issue. This issue contains an article from a Medical Director's viewpoint on "Avoiding Bad Faith Denials of Medical Claims." It lets you in on how insurance carriers try to protect themselves against bad faith claims, which are expensive because they involve punitive damages. The article is 6 pages long and is chock-full of information.