with Brooke Gladstone and William Shernoff
Even more than the legal profession, even more than I daresay, the
media, the avatar of professional slime for the public on the eve of
the 21st century seems to be the HMO. At least in the United States.
This is OnHealth Live, I'm Brooke Gladstone.
I was sitting in a crowded movie house
watching As Good As It Gets, and when Helen Hunt's character lashes
out at her HMO, the audience of jaded Brooklynites burst into loud
and spontaneous applause. Hating the institution of the HMO has
become a national passion.
We are suspicious of HMOs because they
literally hold over us, the power of life and death. Reasonable
arguments about cost and efficiency are not received reasonably by
parents whose child is suffering and when the arguments are
unreasonable, we rage and then often, we sue. And that's where our
guest comes in.
William Shernoff is a lawyer who
specializes in these matters and author of the book Fight Back and
Win, how to get your HMO to pay up. Welcome. Thank you so much for
Thank you for having me, Brooke.
I'm gonna start out with a nice word about HMOs. This is from Chuck
in Rhode Island. He said there's a lot of talk about fighting your
HMO lately. I have had Harvard Pilgrim here in Rhode Island since
actually there were Rhode Island -
- they were the Rhode Island group
health association. I've received better care, had fewer problems,
faster appointments and referrals than I did when I could select my
own physician with Blue Cross. I had more problems with having to
get second opinions with Blue Cross -
- and frankly my doctor's both better
educated and a better physician overall. Why would I want to fight
my HMO over the rude and slow pharmacist. There are a lot of HMOs
that work really well, aren't there?
Well yes, there are some and also, I think most of them work pretty
well for, like routine stuff. I think most people that go in for
checkups for just routine illnesses - colds, flu, stuff like that,
they're pretty good at that. I mean they're really -
- that's the name of the organization
is a health maintenance organization. So I would say on maintenance
they're pretty good, but the problem really comes in when somebody
has a serious illness or injury that's going to cost some money to
treat. And when that happens, people find that because of their cost
consciousness and because they make more money by the less medical
treatment they give, then it becomes a real problem because they
don't want to refer to specialists -
- they don't want to give people
expensive treatment like high dose chemotherapy for cancer or bone
marrow transplants or -
I think we need to back up here and talk about what you've just
referred to, which is the arcane structure of many HMOs. Let's start
with capitation. This is a phrase that a lot of - a word that a lot
of people may not know and yet it's at the heart of a lot of the
problems with HMOs.
It really is. It's at the root of the problem. We should back up
and, and start with what's called fee for service, which we were 10,
15 years ago, that caused the problem. That means that when there's
a medical service performed, there was a fee for it.
So if a doctor took one x-ray, he got
paid for one. If he took 3, he got paid for 3. If he took 5, he got
paid for 5. So the incentive in the fee for service, a lot of people
said was to give more treatment than was needed just to get money
and it drove the cost of healthcare up.
And so then HMOs came on the scene and
they said well we'll - we'll work on a different system. Which is
capitation as you mentioned. But that's just as bad because that's
the other extreme. That says you get so much money, let's say $500
per month per head to take care of a person. So if you don't give
them any medical care, the $500 is pure profit. If you give $1000 a
month medical care, you lost $500 on that person.
So now the motivation is to provide less service, rather than more.
Right and capitation really ought to be outlawed because in
healthcare, we cannot have a system that gives incentives to people
to deny medical care. That's just - seems like it's almost
unAmerican. But it's going on and to make matters worse, many HMOs
give financial incentives like bonuses or revenue sharing to doctors
or administrators to deny medical care.
So that if they do deny the medical
care, they're gonna make more profit themselves. And that's, that's
really unconscionable in most people's minds.
Well what are the situations, the medical conditions that pop up
most often in your practice? You talked about chemotherapy. What
areas are particularly problematical to HMOs? I think you mentioned
high risk pregnancies and chronic diseases - [BOTH SPEAK AT ONCE]
High risk pregnancy, chronic diseases, breast cancer where most of
the - if it's advanced you need a bone marrow transplant and high
dose chemotherapy, all kinds of cancer treatment which is very very
expensive. Skilled nursing care which is expensive though they'll -
- they'll want to send somebody to a
facility that is - is not really skilled nursing care.
Rehabilitation is another area where people have serious serious
injuries and they need to learn how to walk again or they lea - need
to learn how to talk again. Instead of going to these really
credible and good institutes that have these specialist rehab
doctors, they'll send somebody to a - like a nursing facility that
costs one half the price -
- but there's really no credible rehab
at that facility. So almost anywhere you look when it gets to be
specialized and expensive, the HMOs are, are really hard line and,
and sometimes - and we've had cases like this, we just had a case
last month where -
- where the treating doctor at the HMO
and the specialist at the HMO recommended that our client get a
special treatment for his stomach cancer and it took 45 days just to
get approval for that. And by that time, his cancer had
And he was in real trouble.
How can an HMO justify denying chemotherapy or bone marrow
transplants? What, what reasons can they give?
Well they come up with all kinds of reasons. The main reason they
usually come up with that I see in my law practice is they say it's
experimental. And that they are not obliged to give experimental
treatment. However, there's a couple problems with that.
In the case that I just cited, there
was no exclusion in this person's HMO plan for experimental
treatment, so they were really off base not paying for it when the
plan itself did not exclude it.
Well what reason did they give?
Well they just said it was experimental and, and that was the end
of, that was their reason. And many times it's the weight of the
medical authority in this country is that it's not experimental.
It's - it's routine. But you get into these arguments - whether it's
experimental or not experimental. Whether it's investigational or
Whether this is custodial care or it's
really bona fide medical care. Whether the person really ne - needs
the treatment as medically necessary. One of the big problems though
is the - a lot of HMOs allow the administrators to overrule the
Well we have a question that relates to that so let me ask you, and
then we'll go back and discuss the whole issue. Mary Lee in Florida
wants to know, what steps should I take to get my insurance carrier
Health Options to cover medications that are prescribed by my
In one case, they stopped covering
Voltarin[?] which has been covered for many years. My physician
tried 2 or more similar medications that were covered but neither
brought the same result as the discontinued coverage medication.
And she talks about how she strongly
feels that no HMO or insurance company should be overruling her
physician unless they all have medical licenses. What do you do over
this medicine issue?
Well she's got a very good point because they shouldn't be
overruling the doctor. And I'm sure that if - if she looked at the
brochures that the HMO gave her when she first signed up, they
probably had all these glorious promises in there that they would
pay for all her prescription drugs that were recommended by her
And the problem is, they do these
things and they by and large get away with it because they know they
can't be sued for damages if something bad happens because of this
Right. Now before we get to the ERISA law, can you address a little
bit, the first part of her questions. What steps should she take?
Well, I would first have the doctor who prescribed it, go to bat for
her and - and go up the chain of command in the HMO and - and insist
that these drugs that she's being prescribed by him be paid for. It
sounds like there's just no valid reason for them to deny it unless
it's some sort of a drug that's not approved by the Federal Drug
Administration which I doubt from the question that that is the
Well we'll get to - we'll get to ERISA right after this, but we have
another drug question which is related to it. This is from Muriel in
California. When an HMO denies medicine or treatment because it
isn't on the formulary or it's too expensive, how do you get them to
Now that's a good general question and
you devote a lot of your book, Fight Back and Win to offering some
Well yes. There - there's like 3 steps you can, you can appeal
internally to their grievance procedure. Sometimes you can go up the
chain of command in the HMO and make a lot of noise. Sometimes that
will do it.
You could complain in California to
either the department of insurance or the department of corporations
and they might take up your cause. And you can go to the media
sometimes and expose unfair business practice and sometimes that
will get their attention. And of course what really gets their
attention is lawsuits and if they're Medicare recipients, or if they
are government employees or church employees, they can sue. Those
are the 3 major groups that still have the right to take an HMO to
I see we'd better, we'd better get to this ERISA question at least
for the first time right now. And I know this is a particular bete
noire of yours. It's a restriction built into the regulation over
these matters. People who belong to an HMO with certain exceptions,
a couple of which you just mentioned -
- they can't, they can sue to cover
the treatment, they can sue for the cost of the treatment or
medicine they were denied, but they cannot sue for damages. And talk
about when - when that law passed and what the impact of it has
Well that law passed almost 20 some years ago - it was a United
States supreme court decision that, that basically said this law
applies and the state laws don't apply. Unfortunately the federal
law doesn't have any provision in it for remedies for damages.
So people who, who are not - fall into
one of these exception groups, they haVe no remedy. And - and most
HMOs know that so they can be very cavalier in their denials because
you can't take them to task for it, other than through these
procedures I've talked about.
Going to the media or making a lot of
noise or going to the department of corporations. But what really
concerns and scares an HMO is the threat of a lawsuit, because if
they're denying somebody let's say a very needed drug that's
prescribed by the physician and something bad happens to this person
because they don't have the proper drug, they could be sued for a
lot of money and damages if this person is injured or harmed by
their decision to deny coverage.
I thought you said that you couldn't sue them for damages.
Well if they belong - you - you cannot sue them for damages unless
you belong to one of these groups. But my point is, if they change
the law which we're - which is now pending in congress to allow
everybody to sue, all 125 million Americans who get their health
coverage through their employment, then the HMO would think twice
before denying that person the drug.
Because they know that they could be
sued, so they would probably approve that drug, especially if it's
recommended by the treating doctor.
So what is the, what is the status of this law as we speak and
what's it called?
It's called the patients bill of rights. It's now being considered
in the senate and it would give people the right to sue their HMOs.
And would give people the right to choose their doctor.
It would give people the right to, to
get a specialist when they need it. To get emergency treatment when
they need it. It's a whole bill of rights for patients and it's very
important. That's why I devoted a whole chapter in my book to that.
And even put in a sample letter for
people to write their senator or congressman and try to convince
them that this legislation is really needed.
There are a couple of case studies in your book. There was one about
a health insurance company that decided to halt the coverage of
specialized at home care for 7 - a 7 year old boy.
Ultimately the company had to pay more than a million dollars in
emotional distress damages to the mother and son. Were these - was
the mother and son among the exceptions?
Yes, the mother - the husband worked for the - a police, he was a
police officer in one of the, one of the cities in California. And
being a police officer, he worked for the city. And if you work for
a government entity like a state or a city or a school district -
- or any sort of a government entity,
you don't haVe this ERISA problem and, and so she was able to -
actually we were able to get an injunction against the HMO to make
them put back the lifesaving monitors on her - her boy. And also sue
them for damages.
For basically attempting to take away
his life saving equipment.
There is a sentence that you have in your book that you suggest that
anybody who's writing to complain to their HMOs should include. Do
you - do you happen to have that sentence in front of you or - [BOTH
SPEAK AT ONCE]
Well yes, it's basically that you're reserving your right to sue
them under state law. And I think that concerns most HMOs or most
people that work for them because they may not be totally sure
whether you are one of the excepted people that can sue and they may
look at your claim a lot more carefully if they get a letter from
you saying that you're not gonna take this decision laying down.
You're gonna appeal to a higher court. You may even sue them.
You may consult a lawyer, you may
consult the media. You're just not gonna take this laying down
because this is too important to you. This is your health and this
is your life. And you're paying premiums to these people for
So when somebody like that comes
along, that's a red flag to the HMO and they'll take a better look
than somebody who just accepts their denial and goes away.
And if you can hint that you work for a state or government or
public agency, whether or not you do, it might light a fire under
Well it's - that's very possible.
Susan in Indiana writes: she said I've been arguing with Aetna since
November 1998. The problems arose after my husband retired in June
of 98. I work at the same place my husband did. I am now the primary
Aetna failed to update our file and is
now saying that they will not process any more submitted claims
until the file is straightened out. In the meantime, I'm getting
final notices on these bills. What do I do to light a fire under
Boy I don't know. We just - we just had to take Aetna to court on a
case where the jury found that the - Aetna was responsible for the
death of a young man and stuck the widow with $750,000 worth of
bills and we're still fighting them through the court system even
though the jury came back with a whopping $120 million punitive
damage verdict against them.
So they're just appealing and appealing and appealing.
Yes, they're appealing and appealing and appealing. So sometimes
it's very very difficult to get their attention. And each, each case
is, has to be judged on its own merits too. I mean it's hard - as a
lawyer when people come to me with their problem - I really have to
look at everything.
I have to look at what their health
plan says. Are there really any exclusions that apply? Is the HMO
acting reasonably or are they really off base? It takes a lot of
study and analysis to really figure out who's right and who's wrong.
I'll say and that's actually something that you also spend some time
on in your book. How do you read your own policy? I mean what do you
do about unwritten clauses and exemptions and exceptions? What about
deliberately obfuscatory language?
What should employees look for or ask
about? How can they interpret or translate their own policy?
Well it's very very difficult. The law allows them to write these
policies in strange and difficult language and complex language.
About the best thing you can do, sometimes some of the HMOs put out
handbooks which are supposedly like highlights -
- and written in, in more simple
language. And it's certainly good to go over those because that's
probably the easiest to understand. But you're absolutely correct.
Sometimes these exclusions are buried in the master contract with
the employer that you don't even see.
Well then what - can you offer maybe a set of questions that people
ought to be asking themselves as they look over their - their
Well yes. You can be asking - I would, if I were to join an HMO, I
would want to know for example, do they allow the treating doctor's
decisions on medical treatment to stand or do they have a procedure
where the doctor can be overruled by somebody higher up in the HMO
like some accountant type.
I would stay away from an HMO that
allows that. I would also want to ask, do you give financial
incentives to doctors or administrators to deny medical care?
And will the insurance company tell you whether they do or they
Well they probably won't, but if you insist on getting the contract
between them and the doctor, they - you might get it. I mean it is
difficult. I would have to tell you that we, we get them because
we've subpoenaed them once we sue them.
And we find out that they do indeed
have these clauses where people get incentives to deny medical care.
They may, they may tell you, they may not. A lot of states are
passing laws which says they have to disclose everything.
Is that in the patients bill of rights?
Yes, it is. It prohibits that in the patients bill of rights. It
prohibits financial incentives to deny medical care. So I would, I
would want to know that. I would want to know how many specialists
they have on their panel because if they have to go outside of
their, their network, it's more expensive to them and they're
reluctant to do it.
So if you have an HMO that has a wide
variety of specialists in their network, that's better for you
because then you're gonna probably get to a specialist a lot easier
than if they have to go outside their network.
And is that information generally available?
That usually is available. They usually will tell you if they have a
cardiologist or two cardiologists or do they have a specialist in
neurology or do they have a specialist in, in oncology. They, they
usually try to brag about that.
Like how many specialists they have.
And so that's - that's probably one of the most easily received or
gotten bits of information you could - you could get. And then you
might try to find out if you can from the state department of
insurance or corporations, how many complaints have been registered
against this HMO in the last year.
And is their complaint ratio higher or
lower than other HMOs. That you might be able to find out.
Charles in Los Angeles addresses a question or answers a question
that you address in your book about coverage after leaving a job. He
says I am a registered nurse and I used to work for Kaiser
Permanente. I left the organization last November and now work for a
smaller company in Monrovia.
In the 3 months that it took to
qualify for benefits on the new job, Kaiser sent me a letter denying
responsibility for any expenses incurred in getting treatment
anywhere. I ended up not needing any medical care during that period
but my question is, can they really legally deny me service unless I
pay up front?
That's that weird space when you leave
Well that is a real problem area because if you leave - if you leave
a job, even if you're [ ? ] claims. The worst problem is if you get
so hurt so bad or you get a serious ill - illness and you have to
leave your job because your employer doesn't want to keep you on
anymore because you're too sick to work -
- they can actually stop your claim by
saying that the coverage is now gone because you're not working
So the answer to Charles is yes, they can legally deny you service.
Although I wonder whether the company that you work for can legally
fire you if you become sick. [BOTH SPEAK AT ONCE]
Well they can - well yes, if you, if you're not, if you're not able
to work anymore. But there is a provision called COBRA which is an
acronym for another federal law which mandates that the employer has
to offer you continuing coverage under COBRA when you leave
employment for at least -
- usually it's around 18 months. But
you have to pay the premium for it and the coverage is not as great
as it was when you were working there.
Here's a question from Fyodor in Brooklyn. He says I am not a doctor
and I don't work for an insurance company. I hate insurance
companies but if the insurance companies felt pressured to approve
every frivolous $100 prescription when a $20 generic would do just
as well for fear of triggering a lawsuit if they didn't, wouldn't
premiums go through the roof?
Well of course if they did that. If, if an insurance company felt
pressured just to pay every, every claim the cost of - of healthcare
would go up. We're not certainly advocating that. What we're
advocating is that they certainly have the right to deny frivolous
claims and frivolous procedures.
We're not talking about that. We're
talking about legitimate claims that are recommendedby even their
doctors. And then somebody upstairs denies it, based on cost. And
somebody that's never even seen the patient.
Right that's - that's the problem.
That's the real problem. Not - not the - we would grant them the
right to deny frivolous drugs, frivolous treatments that are not
going to help anybody. We agree
I think I should read Cynthia's letter. Cynthia from Houston who
sounds a lot like our Fyodor in Brooklyn. She says mine is not a
question but a comment. I have worked at an HMO for several years
now and the patients, while sometimes knowledgeable and willing to
listen to reason, are for the most part, the worst patients I have
They think because they pay $10 or in
some cases $5, they can go to the doctor's office like they're going
in to have a haircut. They walk in unannounced and demand to be
seen. We are constantly fielding ridiculous requests all day long
because they think HMO are their personal doctors on call.
Yes, sometimes there's a need for
assertiveness but most of the time it is ridiculous. Someone should
speak up for the doctors and their staff that have to put up with
these people. HMO patients are among the worst I have ever seen.
I think she's - she probably has a
good case here to be treated for stress related disorder. She sounds
very sick of them.
Well I think this sounds to me like a person who works for an HMO
and you can see her attitude. She doesn't like the patients at all.
She's - she's definitely against by and large as a general
proposition patients because she thinks they're -
- they're demanding, etc. etc. So
here's somebody that works for an organization that's supposed to
take care of people and she starts with a chip on her shoulder.
Well let's - maybe she didn't start that way. Maybe patients are
wrong to consider their HMO doctors as their personal doctors on
call. Maybe they are asking too much for the amount of money they
But that's what a, that's what an HMO is. And if you look at the
brochure that they put out, they entice people in there saying that
we're gonna give you the best medical care. You're gonna get a
doctor of your choosing. They're gonna take care of you.
That's the way it should be. In other
words - most doctors that I have talked to are upset with HMOs
themselves. They don't like the fact that they're overruled by
bureaucrats and most of the doctor and doctor organizations are for
the patients bill of rights.
But you will credit the - the notion that sometimes people are
asking too much from their, from their health organization.
Well of course you always get in any system, some people who are
demanding. I mean I - I'm a lawyer, I have a law firm. By and large
my clients are - are nice people who have serious problems that need
taking care of.
Once in a while, I get people who -
whose personalities aren't the greatest and they are over demanding
and overbearing, but that's usually a very small percentage.
Rene in Ashtabula says, ever since our changed their name from Blue
Cross Blue Shield to Medical Mutual, we've had nothing but problems.
Here's an example. My 6 year old son needed hearing aids, both ears.
The family physician referred him to a specialist and that doctor
wanted tests done to figure out why he lost his hearing.
An EKG, MRI, urine and blood work were
all ordered. Two of the tests were done that day. Several weeks
later we got a denial letter and a bill. Could you please tell me
how we can be denied if there is an order from the doctor?
They - there you go, that's the typical case. I can't tell her. I
don't understand that. I think it's illegal. If that person has the
right to sue, I would say that they have a good case. I'm with that
person. I don't understand it either.
Charles in New Hampshire writes, how can I be sure that I get the
right tests that are needed? For example an MRI, which are
Right. And that's, that's what people worry about with the HMOs
because if it's an expensive test or an expensive procedure, the
HMOs are a little reluctant to - if - if it's a questionable call,
whether the person should or should not get this test, they usually
err on the side of not giving it because the HMO is a profit driven
organization. Most of them are Wall Street insurance companies.
Owned - Aetna and others are all big
big insurance companies. They make their money by denying medical
care on the capitation system so if there's a benefit of the doubt
to be given it's usually given to the HMO instead of the patient.
And that's why at the top, you talked
about Helen Hunt and her remark, people are aware of the fact and
they're outraged by the fact that for healthcare, that these close
calls are being made in the name of profit and not in the name of
I haVe to say that the, the one thing that I found a bit
disheartening about your book is that you offer long and exhaustive
suggestions for what people can do to fight their HMO but in the
end, there's no guarantee. In fact there's -
- there's not even all that much of an
increased probability that you're going to get any satisfaction.
What is the - what do you think are the chances that people can
actually get what they need paid for, paid for?
Well that's a very good question. The - the book was written for 2
purposes. One is I did - I tried to give some practical advice in a
very terrible system as to how to possibly maximize the chances of
getting some results. And you're right, there's no guarantee.
I think the most important part of the
book where there would be a guarantee is where I say we have to
change the law so that we build in these guarantees and make it
illegal for them to do the things that they're now doing. And that's
why on page 89 I have a sample letter to a member of congress
telling them to pass the bill that is now in front of congress to
give people these guarantees that you're talking about.
And this is very serious. We could
have these guarantees by the end of the year, including the right to
sue. Now the HMO lobby and other strong lobbies are very much
against it and they've been able to garner some political support
with some who are -
- are more or less on the side of the
HMOs in this issue.
But if the patients bill of rights is passed, won't that drive the
cost of insurance and healthcare ever higher?
Well according to the study done by the congressional budget office
which is used by both Democrats and Republicans - it is very
credible, it will raise the premiums 1.3 percent which is really
negligible. And for - for what it will guarantee, I think almost
everybody in America would say golly, let's get that.
We can have all these guarantees that
we really need and all these horrible stories will disappear -
I'm - I'm guessing that the HMO lobby has come up with a different
Sure they have.
What's their figure?
Well they, they don't have any specific figure but their lobby says
God, if you allow these lawsuits, all these lawyers are gonna be
suing and there's gonna be a flood of litigation and the lawyers are
gonna be rich and it's gonna increase the cost of healthcare
They come up with all these wild
accusations. They always do that. Every time you have something
where you want to regulate the HMOs and make them pay what they're
supposed to pay, they say it's gonna cost more. It's because they
want to scare people away from it.
That's - that's been their public
relations scheme for a hundred years.
We've got about 7 minutes left so I want to make sure we get to some
more questions here. This is about a couple that has coverage and I
know that you suggest in your book that if you have the option of
having 2 insurance programs rather than just one, you should do it.
Roger in Michigan says I work for
General Motors. They no longer pay the portion of the bill to the
doctor that the other insurance - let me - well I'll take the
question from the top. This is not so much a question about HMOs as
it is about the coordination of benefits when 2 married people both
have health insurance.
I work for General Motors. They no
longer pay the portion of the bills to the doctor that the other
insurance did not cover, even if the amount is less than what they
would have covered if they were the only insurer. Have you followed
that so far?
Well what he's talking about is coordination of benefits when you
have two plans. One plan is usually primary and another is secondary
and sometimes the secondary plan pays what, what the primary plan
does not pay. So you - you end up with a lot more coverage when you
have 2 people being -
- being a husband and wife working at
different employers and having different coverages. So -
But wait a minute, let me finish Roger's letter because this is
what's upsetting him. They also charged the amount that was paid by
the other carrier against my annual benefit for dental as if they
were the ones who paid it.
Thus reducing what I and my dependents
were eligible for under their insurance. Is this legal?
Well that sounds wrong to me. I mean - but there's so many things
that I see in my law practice that I think are wrong and that's why
I - I battle insurance companies all the time on behalf of people
like that because they do it.
And they assume that most people won't
complain or do anything about it so they get away with it. And
that's - that's been the nature of the game for so long with
insurance - that that's why insurance companies I think have a
fairly bad reputation.
Because they don't really seem to be
interested in - in taking care of people's problems. Brooke, can I -
am I allowed to mention where people can obtain this book?
As a matter of fact, what I'd like you to do is mention where they
can obtain the book and also other places where they can find out
information. In the back of the book you list a number of
organizations and places they can go for information.
So mention where they can get your
book and also some other sources.
Certainly. The book is Fight Back and Win. And you can order it
through 1 800 All Book. That's A-l-l B-o-o-k. Or Amazon.com. Or your
I think we've gotten a clear idea of where to get your book. What
about some other places to get information. [BOTH SPEAK AT ONCE]
All right. Some other places - there's a very good organization that
fights for consumers out in California called Consumers for Quality
Care. And they can be reached at phone numbers 310 392 0522.
Great, what about on the east coast?
On the east coast, there's a really good organization called
Families USA, Washington DC. Phone number 202 628 3030.
That sounds great. Let me, let me get in a quick question about
preexisting conditions. You devote quite a lot of time in your book
to that. Candida in California says, I was with an HMO for 2 years
on a group plan, then changed jobs.
I asked for a continuation of coverage
from my HMO under individual coverage. I was denied for a condition
that the HMO had covered for 2 years which is not a serious
condition. Is this legal and if it isn't, what can I do about it?
Well, they used to be doing that a lot but congress did pass a law
last year which did make it illegal for - at least in group policies
for insurance companies to deny claims on preexisting conditions in
So one has to check the most recent
law on that. And then you really come down to, what's really a
preexisting condition, because everybody has some sort of
preexisting condition. And the question is, was it a condition that
- that disabled you before or was
diagnosed before? Because if it wasn't, then under the law it may
not even be considered a preexisting condition at all.
Aren't HMOs changing for the better? Do you see any evidence of
improvement and which HMO do you think has the best track record for
handling customers complaints in a fair and effective way?
Well, from where I sit, I see people come to my office in droves and
it's getting worse because - so I don't see any improvement at all.
They don't seem to be motivated to improve. They seem to just be
more interested in making money.
And we had a guy out in Los Angeles
who burned himself up on the freeway, committed suicide after he put
a big banner out on the freeway and stopped traffic for like 4 hours
and the big banner said, HMOs are in it for - for the money.
And I think that's reflective of what,
from that scene to the Hel - Helen Hunt line in that movie, to all
the outrage that I'm seeing and hearing about -
And - and pressure from congress. Surely all of this kind of
pressure is having some impact.
Oh, yeah. That's why we have the patient bill of rights up but - I
just spent 2 days in Washington DC and - and people there are
telling me that, that they're not getting enough letters and calls
and faxes about the patient's bill of rights.
They think maybe the general public
has maybe gone to sleep or they're in impeachment doubt or whatever
the case may be people seem to not have the level of outrage that
they did six months ago. So I'm hoping that the public will once
again rise up and demand their rights.
Now I'm going to get back to you with one last really quick question
and this is again from Rene in Ashtabula. You remember about the
woman whose son had 2 hearing aids and there were a bunch of tests
taken and the HMO denied pay - denied the tests -
- or denied paying for them after the
doctor had ordered them.
And what she wants to know is, what measures can she take?
Well where does she live?
In Ashtabula. Where is Ashtabula? I don't know - [BOTH SPEAK AT
I have no idea. [LAUGHS].
It may be a state that she can, she can either sue or - or threaten
to sue or go to the department of insurance in that state or that's
a good case to take to the media.
And probably one of these two organizations. Did you -
- how about one organization in the south? Do you have one in the
Oh, let me see, I have, I have about 10 organizations as I recall
listed. Let me see, south - there's a center for patient advocacy in
McLean, Virginia and that phone number is 800 846 7444.
I think we're gonna have to stop there even though I know we could
go on for another hour and a half. Thank you so much for being with
us Mr. Shernoff.
William Shernoff is a consumer attorney and author of Fight Back and
Win, how to get your HMO to pay up. He joins us from a hotel in -
hotel room in New York where he's on a book tour. Next week we'll
discuss blending alternative medicine and conventional care.
Two doctors who set up a New York city
hospital unit devoted to doing just that will join me here in our
studios. That's Tuesday March 30th at our new time, 8 pm eastern, 5
Pacific, or 0100 GMT. Hope you can you join us then.
OnHealth Live netcast
transcripts are available within one week. OnHealth Live is produced
in New York by John Keefe with research by Mary Esselman.
I'm Brooke Gladstone and thanks for