A Waking Nightmare
The tumor embedded in Maria Watanabe's brain went undetected for years. All the symptoms were there, but she contends her health insurance company denied her care. The survivor is waging a war against her HMO.
PASADENA, Calif.-For almost two years starting in October 2002, Maria Teresa Watanabe suffered from increasingly intense headaches and dizziness that robbed her of sleep and basic daily functions. She had blurry vision spells and blackouts that once made her fall down a flight of stairs with her baby cradled in her arms.
What could it be? She had a nagging feeling that her symptoms were similar to a cousin's who died of a brain tumor, so the mother of two confided in her primary-care physician who repeatedly requested from Maria's health insurance company to allow her to see a neurologist and get the appropriate tests. Each request was denied with the explanation that Maria's condition did not meet "medical necessity criteria."
"I was still scared," said Maria, but since the medical director of her health maintenance organization (HMO) didn't seem to think anything was amiss, she thought "maybe there's nothing wrong with me."
So in July 2003, Maria, along with her husband Hiroyoshi and their two daughters Yurika and Mika, traveled to Tokyo. Her pain intensified, so family members took Maria to a local hospital where she described to the doctor her symptoms and her medical history. He ordered a magnetic brain imaging (MRI) scan the same day.
"The same day," she repeated. "This is the test that I have been waiting so long for [in the United States]."
The scan revealed her worst nightmare: Maria had a brain tumor.
'If I be quiet, they will do it again.'
Four years later sitting in her attorney's Pasadena office against a cerulean sky, Maria, now 42, begins to cry.
"I was thinking I was going to die. I was thinking, I won't see her grow up," she said about her daughter Mika, now five.
The pig-tailed girl looks up from her coloring books and notices the tears.
"Mommy, why are you crying? She cries all the time."
"Mommy is talking about when she got sick. Do you remember that?"
The memory of such tumultuous times still carries sharp barbs, but after the tears are wiped away, her face stiffens in determination.
"It could happen to anybody. It happened to me. I don't want it to happen to my children, so I was thinking I have to do something. They have to be aware of what they are doing," said Maria. "If I be quiet, they will do it again."
So Maria decided to speak out and with her attorney Scott Glovsky, she sued her HMO, Blue Shield of California, for breach of duty and contract and unfair business practices. The complaint filed at the Los Angeles Superior Court in 2005 emphasized the fact that Maria had to travel outside of the U.S. to get the medical care she needed.
The cyst in the back base of her head blocked the flow of fluids from her brain to her spinal cord. After it was discovered in Japan, the Watanabe family decided to cut their vacation short and come back to the U.S. for the risky procedure. Maria had her first surgery to drain the cyst a few days after returning home, and two additional surgeries a year later.
Her health insurance covered the surgeries, but Maria was outraged that her HMO repeatedly denied her requests to see specialists and get tested.
"I would like to ask why I wasn't sent to a neurologist last January when I first informed you about my headache," wrote Maria angrily in a July 21, 2003, letter from Japan that was faxed to her primary care physician, Dr. Irina Jasper in Los Angeles. "I have two children who need me desperately. I don't want to die and leave my family."
Today, Maria's physical scars are no longer visible, but she said because her condition went so long without being detected, the pressure against her optic nerves has caused her to lose some of her peripheral vision. Even a request to see an ophthalmologist after her first surgery was denied, her attorney said.
'She received first class care.'
"The first time I came [to the U.S.], my husband told me medical insurance is very important here. He said if you got sick, the only way to go to the hospital is to have insurance," said Maria, a native of the Philippines where she met her Shin Issei husband while working in a production company. They married in 1992 and now live in Eagle Rock, a suburb of Los Angeles.
Maria's story was featured in the controversial Michael Moore documentary "Sicko," which critically dissects the health care industry. But with HMOs in general, Glovsky said, reality is far worse.
In California, most HMOs enter contracts with groups of physicians called "independent practice associations" (IPAs) to provide medical care to subscribers. In Maria's case, her IPA was the Good Samaritan Medical Practice Association (GSMPA).
"None of the medial decision-making was done by Blue Shield," said David Seldin, a Blue Shield spokesperson, who added that they leave it up to medical professionals to determine a patient's medical needs. Blue Shield cuts the checks as necessary. In this case, Seldin said Blue Shield did not even know about Maria's condition until she filed the lawsuit.
Usually, the IPAs send all documents pertaining to medical treatments every six months. Blue Shield receives stacks of thousands that auditors then spot check. Blue Shield is not reviewing each case one-by-one, Seldin explained.
Dr. Glen Hollinger, the GSMPA medical director, did overrule Maria's MRI request, said Seldin, but added that if a person enrolled in an HMO group feels that the decision is wrong they can appeal to the health plan or the state department of managed health care.
"She had the right to appeal. She didn't avail herself to that," he said. "When the headaches didn't go away. She asked to see a neurologist, who asked for a CAT scan. The CAT scan was approved, but she didn't get it."
"She was seen by numerous specialists in our medical group," said Hollinger, who added that Maria is still being treated by GSMPA. "She continued care within our medical care. She received first class care."
In October 2006, Maria reached a settlement with GSMPA of $150,000. The jury determined Blue Shield did breach its contract and caused harm of $65 in damages - for an optometrist visit, said Seldin, who added that the court ruled in favor of Blue Shield.
But Glovsky said the jury ruled that Blue Shield did breach their contract. They are currently in appeal.
"Insurance companies need to live up to their promises and give people what they promise to give them when they take their money," said Glovsky.
'... the health care system needs to be fixed.'
Spurred by Moore's scathing documentary and recent national headlines about the failing health care system, many HMOs and health care providers have been placed under a microscope. Experts say the conditions are not getting any better. Earlier this month, a national human resources firm projected a nationwide hike in HMO monthly premiums by 14.1 percent in 2008, the highest rate in four years.
Even health insurance companies are echoing the call for change.
"Blue Shield's view is that, broadly, the health care system needs to be fixed. We've been the leader in championing universal coverage," said Seldin.
For now, many say the key to navigating the health care system is education.
In California, the Office of the Patient Advocate (OPA), an independent state government office, exists to inform consumers about their rights and responsibilities as HMO enrollees.
Every year, the OPA publishes an annual internet-based report card on the quality of HMO services. In 2006, the OPA rated the state's major HMOs based on two categories: quality of care based on meeting national standards and quality of care based on member surveys. Out of four stars, the HMO with the best overall rating in both categories was Kaiser Permanente with three stars. Blue Shield received "fair" ratings.
The Department of Managed Health Care (DMHC), which oversees all HMOs in California, also has an HMO Help Center with a toll-free hotline. The center helps feed consumers information about the best plan for their individual needs and how to proceed with an independent medical review, if qualified.
The number of inquiries is increasing, said Laura Dooley of the DMHC. On average, they receive about 6,500 formal complaints a year.
The key to understanding your health care system is awareness, she said.
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