In November of 1996, I had a physical exam with my long-time physician. We discussed my symptoms and his exam confirmed that I have a condition called endometriosis. This is when the lining in the uterus over-grows, and makes pregnancy nearly impossible. Since my doctor is not contracted with my HMO, I called my primary care physician and he did another thorough exam and confirmed the diagnosis. He then prescribed medication which I have been taking since December of 1996.
In February of 1997, my primary care physician then referred me to an OB-GYN specialist who was also contracted with my HMO. He too confirmed the diagnosis and recommended I have surgery to take care of the problem. He recommended a follow-up with invitro-fertilization.
In March of 1997, my primary doctor’s office called and told me that my HMO had denied the claim for surgery. The office manager also told me that my doctor could no longer help me because he had dropped my HMO as of March 1st. She suggested that I call my HMO directly.
I called my HMO and talked to a Member Services Representative. I was told that the best course of action was to re-submit the claim to a Review Board. I waited a month and in the middle of April called my HMO.
In May, I spoke with a lady from Member Services. She told me my HMO had once again denied the claim due to the “way my doctor had worded the diagnosis.” Although she never told me the doctor’s wording, she did say that the claim was for follow-up invitro-ertilization treatments which she said were not covered by my policy.
I next called my union which provides my insurance coverage. The union representative reviewed my benefit package with me, and in fact, I do have invitro-fertilization coverage.
On May 7, 1997, I spoke to another Member Services Representative and told her everything that had happened. She assigned me to a different primary care doctor and requested that I go to him to get another referral to see a specialist. In a perfect world, that specialist would again submit a diagnosis to my HMO, and then my HMO would again review the claim.
When I called my new primary care physician, I was told he no longer was accepting patients from my HMO. Urrrrh!!!
Again I called my HMO, and spoke to the same Member Services Representative. She said she would find yet another primary care physician, however she informed me there was none practicing in the Santa Barbara area. She said she could assign me a doctor an hour to the north or 50 minutes to the south. I declined both, and requested an HMO doctor in Santa Barbara area, even if that doctor practiced outside of the medical group.
This ordeal lasted 8 months and I have never received written correspondence from my HMO regarding why my HMO claims have been denied. I am at a complete loss about how to deal with the run-around I have received. My repetitive requests to speak to supervisors at my HMO have been stone-walled and I cannot understand my HMO’s negligence, especially in view of the fact that the procedure I need can be performed on an out-patient basis.
My experience tells me that my HMO operates in a way that leaves their injured so upset and frustrated that the person either gives up or seeks another medical care provider. Because I get my health care though my employer, the ERISA loophole shields my HMO from damages for delaying and denying this medically appropriate treatment.
I had to take care of my medical condition and time was of the essence if I ever planned to have children. (To this day I have been unable to conceive.) I wish to see the ERISA loophole closed and HMOs to be held accountable so that the consumer has a remedy when they are faced with the kind of stalling tactics that were employed by my HMO in my case.