The Kaiser Papers A Public Service Web Site
I
n Copyright Since September 11, 2000
Help for Kaiser Permanente Patients on this public service web site.
Permission is granted to mirror if credit to the source is given and the
material is not offered for sale. The Kaiser Papers is not by Kaiser but is ABOUT Kaiser
ABOUT US| CONTACT | WHY THE KAISERPAPERS | MCRC |
Why the thistle is used as a logo on these web pages. |
 
Kaiser Permanente Patient Horror Story

Marianne Lynch
Sacramento, CA

HMO denies hysterectomy recommended by doctor

Ten months ago, during a routine physical, my doctor found a suspicious growth. The specialist I was referred to, recommended surgery. One surgical option was removing the growth. That option offered no guarantee other growths of that type would not reappear.

The second option would require a more invasive procedure, and a hospital stay, but would guarantee no other growths of that type would recur. As the growth, and its location, caused me considerable physical and emotional distress, the specialist and I agreed , the more invasive procedure would be best for my overall health. I sought a second opinion and the second specialist concurred.

After being scheduled for surgery, the gatekeeper consultant firm used by my HMO denied the procedure three days prior to my hospital admission, claiming that the procedure was "not medically necessary. " In the denial letter, they stated that my specialists should request the lesser procedure. The letter of denial was not even signed by a person, but in the name of the company.

I responded by submitting my attending physician's letters stating, in my specific case, the more invasive procedure was "medically necessary" for me. Still they continued to deny the procedure recommended by my doctor in favor of the lesser expensive treatment.

After two months of letters, appeals and a complaint to the California Department of Corporations, my HMO finally approved the procedure though their gatekeeping consultant firm continues to this day to oppose authorization of the procedure.

I hope with the passage of Proposition 216, other patients who have medical problems will not be forced to go through what I did. 

kaiserpapers.org