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Read Making a Killing

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PATIENT STORY

HMO Denies Quadriplegic Child Vital Therapy, Thus the Chance to Walk

Ethan Bedrick - Raleigh, NC
According to court records:

Ethan Bedrick was born January 28, 1992. His delivery had complications and he was asphyxiated. As a result, he suffers from severe cerebral palsy and spastic quadriplegia. Hypertonia from the quadriplegia impairs the motor functions in all four of his limbs.

The terrible thing about hypertonia is that without proper treatment it can get much worse. The hypertonic muscles must be stretched regularly, to avoid shortening and inflexibility. Therefore, Ethan was put on an intense regimen of physical, occupational and speech therapy to help him throughout his development.

When he was 14 months old, Ethan's HMO unexpectedly cut off coverage of his speech therapy, and limited his physical and occupational therapy to only 15 sessions per year. This sudden change was at the recommendation of an HMO doctor who performed a "utilization review" of Ethan's case. The HMO has a doctor perform a "utilization review" to look for places to cut off or reduce unnecessary services, and thereby reduce the cost to the HMO. The reviewing HMO doctor called Ethan's pediatrician who told her that Ethan had a 50% chance to be able to walk by the age of 5. The reviewing HMO doctor decided this prognosis was a "minimal benefit" of further therapy, and so Ethan's coverage was cut. The HMO doctor never even met personally with Ethan, his family, or his regular doctors during the review.

The denied coverage was finally reviewed a second time in October of 1993. This time, the HMO affirmed its position with a second HMO doctor. Though several months had passed since the initial review, the new HMO doctor did not update Ethan's file or contact any of his physicians. Instead, he relied only on his general knowledge and a single New England Journal of Medicine article on physical therapy and child development. The article was published in 1988, four years before Ethan was even born!

In addition, the second HMO doctor further denied Ethan prescribed therapeutic equipment, including a bath chair and an upright walker. It was claimed that they were merely "convenience items," not to be covered by the HMO.

In 1994, exhausted of options, the Bedricks filed suit in state court against the HMO. The HMO had the suit removed to federal court where they would be shielded by the federal ERISA law.

The Federal Circuit Court concluded in 1996, that the HMO's decision to restrict Ethan's therapy was "arbitrary and capricious," as their doctors' opinions were groundless and riddled with conflict. The court also ruled that the HMO's guidelines do not require "significant progress" as a precondition to providing medically necessary treatments.

The court even stated, that "it is as important not to get worse as it is to get better. The implication that walking by age five... would not be 'significant progress' for this unfortunate child is simply revolting."

Still, because the lawsuit was preempted by ERISA, the Bedricks are left with no means for restitution for Ethan's therapy loss, and face the future with only limited care and equipment for him.

Over the period of reviews and litigation, Ethan lost three critical years of therapy that will cost him for life. Until the ERISA law is changed, the HMOs will continue to be unaccountable for their cost- cutting techniques of withholding medically necessary treatments and equipment.




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