• Report:  #2247

Complaint Review: UniCare - Atlanta Georgia & Nationwide

Reported By:
- Tempe, Arizona,

Two Paces West , Suite 600 Atlanta, 30339-0044 Georgia & Nationwide, U.S.A.
Tell us has your experience with this business or person been good? What's this?

March 28, 2000


PO Box 310

Tempe, AZ 85280

RE: Adam Nicholas Mathers, Age 4

Dear Sir:

We request your assistance in saving our 4-year-old son's life.

Adam was born June 1, 1995. It was obvious from the beginning that he wasn't a very healthy child. At 7 months of age, I stopped breastfeeding Adam and he became very ill, first with chronic ear infections, then with chronic sinusitis. X-rays showed his sinuses to be totally occluded. No antibiotic would touch his infection. Then he began having sleep apnea. A CT scan showed his adenoids were swollen to the size of walnuts. 2 surgeries later, he was doing a little better, but far from healthy. With the help of Adam's pediatrician, Dr. Richard

LaMere, Fort Worth, TX, Adam was referred to an immunologist, Dr. Elisa Lange, in Dallas, TX. Dr. Lange ran extensive tests, which showed Adam to have Primary Immune Deficiency (IgA and IgG Subclass 2 & 4 deficiency). In other words, Adam is lacking important antibodies in his blood and mucosal surfaces to fight off bacteria.

Since December 1996, Adam has been receiving intravenous gamma globulin to replace missing antibodies, but the replacement is temporary, so he must receive these IV's every 3-4 weeks. The infusions are quite expensive, currently $1265.00 each. Adam must visit his doctors regularly, and he takes prophylactic antibiotics to fight off the bacteria other peoples (your body and my body) bodies fight off without difficulty. He has developed Chronic Reactive Airway Disease as a result of this deficiency, so he also must use inhalers and nebulizer

treatments for breathing. We live in fear of the day he may receive an infection that he cannot recover from.

Our problem concerns insurance. We were on Harris HMO for several years, without difficulty, but due to the buyout with PacifiCare, we were told that our current benefits could not be guaranteed. We did much research, and chose to switch to UniCare PPO. Little did we know that this would be one of the biggest mistakes of our lives.

UniCare is refusing to cover Adam's infusions. We have disputed and now have been denied a 3rd time. Adam may die without these treatments, and we are scared to death of losing our son. We don't understand how UniCare can be allowed to "legally MURDER our child." We have filed a complaint with the TX Dept. of Insurance, and the Director of Benefits at Harris Hospital (where my husband works), but the wheels turn slow, too slow considering what's at stake -- Adam's life.

In the meantime, Adam's home health agency, Coram Healthcare in Dallas, is requiring us to pay for his infusions -- up front, in cash. We live almost from paycheck to paycheck, and now are looking at having to sell everything we own to keep Adam alive. How can UniCare get by with doing this? They hold $108.00 every 2 weeks out of my husband's paycheck for insurance coverage, but UniCare denies EVERY claim sent to them. How

can this be legal?

What we are asking from you is, if you would please, send a letter in Adam's behalf demanding coverage for all future infusions, plus reimbursement on all claims they have denied since 1-1-2000. We also want reimbursement for all of our "out of pocket expenses" to the doctors and home health agency due to UniCare's refusal to pay. The address is:


Attn: Danielle Hagan

Two Paces West

Suite 600

2727 Paces Ferry Road, N.W.

Atlanta, Georgia 30339-0044

I'm enclosing copies of letters from Adam's doctors.

We thank you in advance for your assistance.


Kenneth & Virginia Mathers

313 N.E. Michael Drive

Burleson, TX 76028

Following are the included letters from Adam's physicians.

March 8, 2000

RE: Adam Mathers DOB 6-1-95

To Whom It May Concern:

Adam Mathers has been a patient of mine since October 1995. Starting at nine months of age, he was in my office for several occurrences of sinusitis and otitis media, which never cleared and required frequent treatments. He was also on Nutramigen for milk/soy allergy during his first year of life. Testing was done in July 1996 showing him to have IgA deficiency. At that time he was referred to Dr. Elisa Lange in Dallas who is an immunologist. Several allergy tests were performed

and medications tried by Dr. Lange. And, in November l996 recinnebded IVGG. This therapy has been continued under the care of Dr. Lange. Adam's health has been much improved.


Richard G. LaMere, M.D., F.A.A.P.

Cook Children's Physician Network

Primary Care Services

1500 West Lancaster, Suite 101

Fort Worth, Texas 76102

Phone 817-870-2910

February 9, 2000

Re: Adam Mathers

DOB: 6-1-95

To Whom It May Concern:

Adam is a four and one-half year old patient of mine with common

variable immunodeficiency and reactive airways disease. Triggers of reactive airways disease include repeated sinusitis and otitis.

He has a history of three episodes of croup and bronchitis during

November 1999, to December 1999. Adam also had episodes of sinusitis monthly from December 1998, through April 1999, as well as one episode of bilateral otitis media.

Adam has improved over the last year with the treatment of intravenous gammaglobulin. His immunoglobulins from July 1996, revealed an IgG of 564, and an IgA of 12, which is low (normal value of 14 to 106), and IgM of 120, which is normal.

Lab work from November 1996 revealed a low IgG2 subclass of 32 (normal 30 to 250), and an IgG4 subclass of 1 (normal to 60). Intravenous gammaglobulin therapy was initiated in December, 1996. In August, 1998, the IgA decreased to 7 (consistent with common variable immunodeficiency). The IgG was normal while on gammaglobulin.

With his recurrent infections, his low IgG sublasses and IgA, and his improvement with intravenous gammaglobulin, I continue to recommend ongoing intravenous gammaglobulin at a dosage of 10 grams every four weeks.

Do not hesitate to call my office if further information is required.


Elisa B. Lange, M.D.

Asthma & Allergy Specialists of North Texas, P.A.

Presbyterian Heart Institute

8440 Walnut Hill Lane, Suite 350

Dallas, Texas 75231

214-373-1773, Fax 214-373-1316

6300 West parker Road, G21

Plano, Texas 75093

972-608-3370, Fax 972-608-3371

1 Updates & Rebuttals


IGNORE what the agent tells you. He has one interest, and one interest only - his commission!

#2Consumer Suggestion

Thu, May 22, 2003

The Mathers' story is very sad, and, unfortunately, very common in health care insurance. PacifiCare is not the only company to blame here. They all do this. It is critical for people to READ THEIR CONTRACT. Everything the company will pay for is in the contract. IGNORE what the agent tells you. He has one interest, and one interest only - his commission! In the Mathers' case, at the risk of sounding insensitive, here's what they SHOULD have done: When they went looking for health care insurance, they should have prepared a checklist of their child's requirements. Then, while sitting with each agent, they should have picked up the phone, called his insurance company (agents do NOT work for the insurance company), told their tale to customer service, and asked for a readout. If they found an insurance company which agreed that it would pay for the items on the checklist, then they should have called again after they received, and read, the contract, and verified. This stuff is critical! Having said all that, be aware that the Mathers' were in a bind anyway. No insurance company wants to take on a "problem". It is very likely that the above calls would have resulted in the Mathers' being told that their child wouldn't be covered fully, if at all. Insurance policies say that it is entirely up to the company what it will pay for, and, that it can change any policy any way with 30 days notice. Blame that on the insurance companies' lobby and Congress. If you have a significant medical problem, and you do not have a group insurance plan, then one of two things is going to happen to you: The insurance company will raise your rates, or, it will eventually cancel "the problem". It's just business. You can't "make" the insurance company pay for something it is not contractually obligated to pay for any more than you can force a car dealtership to sell you a car at less than its price just because you "need" the car. The insurance commissioner is going to look at the Mathers' contract, make sure the inruance company is following the terms of the contract, and, if it is, do nothing. What you "believe" you should get in health care insurance, and what you actually shop for and buy, are almost always significantly different. There is no substitute for doing your homework. The Mathers' situation is unfortunate and sad, but not even close to the worst stories. Do your homework. Health care insurance is not an American "right". It's no different that auto or home insurance.

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