GaryViscio
LOS ANGELES (AP) - The family of a 17-year-old leukemia patient blamed Cigna Corp. on Friday for her death, saying the health insurance giant's initial refusal to pay for a liver transplant contributed to her death.
"They took my daughter away from me," said Nataline Sarkisyan's father, Krikor, with tears in his eyes at a news conference at his lawyer's office.
The Philadelphia-based insurer had initially refused to pay for the procedure, saying it was experimental. The company reversed the decision Thursday as about 150 nurses and community members rallied outside of its office in Glendale in suburban Los Angeles. Nataline died just hours later.
The insurer "maliciously killed" Nataline because it did not want to bear the expense of her transplant and aftercare, said family attorney Mark Geragos. He did not say when or in what court he would file the civil lawsuit.
Geragos also said he would ask the district attorney's office to press murder or manslaughter charges against Cigna, an allegation that one legal expert described as difficult to prove and "a little bit of grandstanding."
A district attorney's office spokeswoman declined to comment, saying it would be inappropriate to do so until Geragos submits evidence supporting his request.
The family's "loss is immeasurable, and our thoughts and prayers are with them," Cigna said in a news release Friday. "We deeply hope that the outpouring of concern, care and love that are being expressed for Nataline's family help them at this time."
Nataline was diagnosed with leukemia at 14 and received a bone marrow transplant from her brother the day before Thanksgiving. She later developed a complication that caused her liver to fail. She was in a vegetative state for some time, her mother Hilda said.
Nataline was taken off life support at the University of California, Los Angeles Medical Center on Thursday, her mother said. Nataline died within the hour.
In a Dec. 11 letter to Cigna, four doctors had appealed to the insurer to reconsider. They said patients in similar situations who undergo transplants have a six-month survival rate of about 65 percent.
One of Nataline's doctors, Robert Venick, declined to comment on her case. UCLA Medical Center staff refused to make her other doctors available for comment.
The case raised the question among at least one medical expert over whether a liver transplant is a viable option for a leukemia patient because of the immune-system-suppressing medication such patients must take to prevent organ rejection.
Such medication, while preserving the transplanted liver, could make the cancer worse.
Transplantation is not an option for leukemia patients because the immunosuppressant drugs "tend to increase the risk and growth of any tumors," said Dr. Stuart Knechtle, who heads the liver transplant program at the University of Wisconsin at Madison and was not commenting specifically on Nataline's case.
The procedure "would be futile," he said.
Geragos' attempt to get the district attorney to press murder and manslaughter charges against Cigna would be difficult to prove unless the defense can show that the company somehow intentionally caused Nataline's death, said Rebecca Lonergan, a law professor at the University of Southern California.
"My personal opinion is that this is a little bit of grandstanding," said Lonergan, a former Los Angeles County and federal prosecutor.
Viscio Law Journal
Welcome to our Journal Section. In this area we're going to post Podcasts and Videocasts. In the case of podcasts you should be able to download each episode onto your MP3 player to listen to at your convenience.
Why are we doing this? Well, we listen to your suggestions and comments. For starters, it is usually easier to understand a concept, such as ERISA, when you hear it or see a presentation then when words are thrown at you on some computer screen. Also, these interactive avenues will allow us to post interviews with Surgeons, Patients and Experts in the field.
Want to suggest a topic, or be interviewed yourself? Email us and let us know.
CIGNA FINALLY GETS BURNED
Yet another reason to stay active against insurance companies as a whole, not just Bariatric Surgery, but all coverage. Who should decide what is covered, you and YOUR doctor, or THEM.
CIGNA decided to pay for the surgery AFTER this poor girls death.
Copyright 2007 The Associated Press. The information contained in the AP news report may not be published, broadcast, rewritten or otherwise distributed without the prior written authority of The Associated Press. Active hyperlinks have been inserted by AOL.
Three D's of Appeals
Three D's of First Level Appeals
Demand full disclosure of denial details. Denials can be vague. Even clearly-stated denials such as “denied due to lack of medical necessity” does not provide you with important information such as the clinical criteria used to assess treatment. Therefore, you should request the specific written limitations, exclusions or internal guidelines which apply to the denial.
Demand review by a qualified professional with consideration given to your internal quality care standards. Clinical denials involving application of treatment standards should be reviewed by a medical professional with similar credentials to the treating professional. Make sure your bariatric appeal is reviewed by a bariatric surgeon. Often this is not the case.
Do not assume that the carrier will follow the policy rules or state rules. This requires being well educated on both state and federal claim processing requirements and potentially applicable utilization review standards. You should also review the denial for compliance with the carrier's contractual obligations. Many carriers miss their own deadlines and are not held accountable.
Demand full disclosure of denial details. Denials can be vague. Even clearly-stated denials such as “denied due to lack of medical necessity” does not provide you with important information such as the clinical criteria used to assess treatment. Therefore, you should request the specific written limitations, exclusions or internal guidelines which apply to the denial.
Demand review by a qualified professional with consideration given to your internal quality care standards. Clinical denials involving application of treatment standards should be reviewed by a medical professional with similar credentials to the treating professional. Make sure your bariatric appeal is reviewed by a bariatric surgeon. Often this is not the case.
Do not assume that the carrier will follow the policy rules or state rules. This requires being well educated on both state and federal claim processing requirements and potentially applicable utilization review standards. You should also review the denial for compliance with the carrier's contractual obligations. Many carriers miss their own deadlines and are not held accountable.
Self Funded or Non Self Funded, that is the question.
Self Funded Plans This type of coverage is common with large corporations. In this situation the employer hires an insurance carrier as a third party administrator to process claims. More importantly, this type of plan is governed by a federal statute known as ERISA (Employee Retirement Income Security Act). ERISA preempts state law. Federal law allows the employer broad discretion in drafting the policy. "Iron Clad" exclusions are possible. Again, each policy as written is different and must be reviewed thoroughly to ensure that the proper procedures are followed. Your surgeon’s office will request authorization in the same manner as they would for a fully insured plan. If you are denied, however, your appeal options may vary. Typically you will be allowed two appeals to the insurance carrier. In some cases your employer would allow an appeal to an external independent review agency. In all situations you would not be afforded the opportunity to appeal to your state’s insurance department should your appeals be denied. If you do receive a final adverse determination from your insurance carrier, your only option after this point would be to sue under ERISA.
The United States Department of Labor provides information on ERISA and Self Funded Plans.
Fully Insured Plans ( Also known as Fully Funded ) This is an insurance plan where the employer charges an insurance premium each month or quarter. Again, your surgeon’s office would request authorization for the surgery, and then if denied your appeal rights would be set by the plan. Typically you are allowed one or two appeals within your carrier and, depending upon the state you live in, an appeal to the insurance department for an independent review.
Tele-Conference Call 12.06
If you click on this link you'll be able to download a four minute podcast which is a recording of a teleconference that took place during the week of December 29, 2006. The call, between my office, my client and a panel from his insurance company is approximately four minutes long. Unlike most calls, this call was very short. The client did not speak as much as most do, and for privacy reasons the recording has been edited to remove personal information. As such, it may appear a bit choppy.
The panel had all of the client's medical records, our appeal including case law and medical research specific to DS cases in his State.
A decision is pending.
Welcome
Post a Comment
Welcome to our first podcast, Click this link to download and listen to the introductory PODCAST