Complaint Review: Kaiser Permanente

Patient's Medical History: Marjorie Dolik had problems with her left foot. Her HMO diagnosed the problem as "osteomyelitis," involving the first metatarsal of her left foot. Marjorie's HMO doctor recommended amputation of her leg above the knee. The doctor also recommended that Marjorie get a second opinion outside of the HMO network. The HMO doctor made clear that the second opinion should come from someone outside of the HMO as Marjorie's HMO primary care physician and the HMO's Assistant Medical Director had both concurred with the diagnosis.

Marjorie was severely disabled and desired to save her only working leg. Her son, Wayne, took her to an out-of-network doctor who advised against the amputation. The non-HMO doctor referred Marjorie to a non-HMO specialist who continued treatment on her foot. At the same time, Marjorie still went to her HMO doctor who continued to recommend amputation during 10 more clinic visits.

The new out-of-network doctor finally told the Doliks that there would have to be an amputation but it would only be at the metatarsal. The original HMO doctor disagreed and maintained the need for an amputation above the knee. Marjorie had the amputation done at the metatarsal. The procedure was done at an out-of-network facility costing the Doliks out-of-pocket expenses.

Upon completion of the surgery, Wayne tried to have his mother transferred back to the HMO facility to recover. Initially, the HMO refused to take Marjorie. Eventually, the HMO admitted Marjorie where she remained for five days.

Next, the original HMO doctor wanted to open up the surgery, because he felt it would not heal. The out-of-network doctor disagreed. The Doliks followed the out-of-network doctor's decision and the wound healed normally.

ORANGE, CA- Angry with the HMO's care, the Doliks decided to seek remedy for being forced out of the HMO for appropriate care. Though Marjorie's claim should have been handled through the Medicare appeals process, the HMO forced the Doliks into a private, binding arbitration hearing. Even the HMO's group policy language stated that Marjorie's type of grievance went through Medicare appeals.

Forced into arbitration, the Doliks were continually delayed a hearing. As a result of delays, the Doliks amassed more and more legal fees. This added to the stress they already felt over Marjorie's condition. Wayne felt this put them further behind in mentally and physically preparing for the arbitration hearing.

Their hearing finally took place two and a half years after they originally filed. At the hearing, Wayne says they felt outmatched because they could only afford a lawyer with limited knowledge and experience in HMO arbitration. Wayne explains that the polished HMO lawyer and seasoned arbitrator were more than they and their lawyer could handle.

The Doliks were left to the HMO arbitrator's mercy. In the end, the Doliks spent nearly $15,000 in legal fees trying to recover over $28,000 in bills they had paid out-of-pocket, yet they lost the arbitration in what they deemed a biased setting.

Wayne Dolik is angry over his mother's care at the HMO and the HMO's use of arbitration.

Wayne states, "These companies think of you [the patient] as a bottom line number. They say 'It's my way or pay.' So we had to pay out-of-pocket. Then to be forced into arbitration- the HMO misconstrued the language of their own contract. I don't think any patient gets justice in an HMO arbitration. The arbitrator was a repeat player at the hearing and he was there to get paid, not to render justice. Truthfully, arbitration with the HMO is a circus and has become an entitlement program for retired judges. There needs to be a way to extend the right to appeal an arbitration, so that the behavior of these HMOs and arbitrators in these private hearings can be publicly scrutinized."

-- Marjorie Dolik's story is reported by her son, Wayne Dolik.

FTCR will continue to fax daily a story of HMO Arbitration Abuse to educate the public on the need for reform. AB 1751 (Kuehl) makes HMO binding arbitration voluntary rather than mandatory.

Scott
Oceanside, California
U.S.A.