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Read Making a Killing

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PATIENT STORY

Heart Patient's Access To Cardiologist Stone-Walled, Dies Due To Mis-Managed Care

Glenn Nealy - New York
According to suit filed by the Nealy family:

In March 1992, 35-year-old Glenn Nealy, the father of two young boys, was notified by his employer that there would be a change in his health care coverage and that he could elect coverage under one of three plans. Glenn chose a managed care company after receiving assurances from its agents that the plan would enable him to continue treatment of his unstable angina and would allow him to see his cardiologist. The doctor was treating Glenn with a complete drug regimen including nitrates, calcium blockers and beta blockers.

On April 2, 1992, at the direction of the managed care company, Glenn went to the office of a participating primary care physician for the purpose of obtaining a "referral" for follow-up treatment by his cardiologist. However, the managed care doctor refused to see Glenn until he had a valid company card. On April 3, Glenn returned to the primary care doctor's office with a copy of his enrollment form, which the company advised would be accepted by their primary care provider. Again, the primary care doctor refused to see Glenn. Between April 2 and April 21, Glenn contacted representatives of the managed care company to obtain a valid card, and it issued two incorrect and invalid cards to Glenn.

On April 9, 1992, the primary care doctor met with Glenn, but refused to give a referral to the cardiologist, professing no knowledge of procedures for allowing referrals. The doctor renewed Glenn's angina medications, but Glenn was unable to fill the prescriptions because the company provided incorrect and invalid information to Glenn's pharmacy.

Between April 9 and May 18, Glenn repeatedly tried to get the insurer to authorize follow-up care by his cardiologist. On April 29, the insurer, in violation of its previous assurances, formally denied in writing Glenn's request for follow-up visits with his caridiologist, because they had "a participating provider in the area." On May 15, after being repeatedly denied authorization to see his cardiologist, Glenn obtained a referral from his new doctor to see a "participating" cardiologist with the managed care company on May 19.

On May 18, Glenn died from a massive heart attack, leaving behind his wife Susan, and his two sons.

Unfortunately for the Nealys, Glenn received his health benefits through his employer. Under ERISA, the only legal remedy available to an injured patient is the cost of the benefit delayed or denied. Susan Nealy cannot recover economic losses -- such as lost wages or salary -- or non-economic losses. Because Glenn never incurred any medical expenses, the managed care company cannot be held responsible for any costs and Susan Nealy has no remedy for the wrongful death of her husband

The District Court for the Southern District of New York had no choice but to dismiss Susan's claims for the breach of contract, misrepresentation and wrongful death.





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