Laurie St. Clair, a 53-year-old, died from cirrhosis of the liver awaiting a liver transplant. A wrongful death suit filed in Los Angeles Superior Court alleges that her medical insurance companies Health Net of California and Healthcare Los Angeles were amid discussions involving payment for the transplant at the time. The two companies were said to be “working out” an agreement necessary because the surgeon was an out-of-network physician.
The plaintiff's attorney claimed the two HMO's were “callous” in ignoring the pleas to have the transplant conducted over a period of four months. He felt the companies delayed while slowly negotiating what was a necessary life-saving procedure. The suit seeks financial compensation for damages that the plaintiff's death has inflicted on her family.
St. Clair had legal custody of five grandchildren, in addition to her three children, who are all named plaintiffs. The claim requests punitive damages, which in California, are reserved for claims where the defendant's actions are deemed to have been knowing or malicious. The suit states the punitive damages should be appropriate for “punishment and to set an example” for reprehensible conduct. The suit further accuses the companies of seeking to increase their profits without regard for the harm caused.
St. Clair had her authorization for the transplant approved; however, the facility did not have a surgeon who was approved in the insurance network. The family unsuccessfully pleaded with both HMOs to expedite a solution. She died among family and friends as her liver no longer functioned, resulting in the body being unable to remove toxins. Her attorney says that delays and denials are often the norm in many of these situations.
California Civil Code says that medical service plan providers and managed care companies have a duty to provide medically necessary services to those enrolled in their benefit plans. Providers may be found liable for failing to provide ordinary care if the following is true:
- The failure in demonstrating care led to delay or denial of the medically recommended service
- As a result of the failure, the enrollee experienced substantial harm
- Substantial harm is defined as death, loss of function in the limbs, deformity, chronically severe pain, or massive economic losses
The costs associated with a liver transplant are extremely significant. According to an estimate from the United Network for Organ Sharing (UNOS), the average billed expenses for the procedure is $577,000. Private insurers may absorb a large percentage of the costs; however, this fluctuates based on the specific policy provisions. Some policies will pay approximately 80% of the hospital charges, leaving the patient to cover the remaining 20%. The costs of the procedure add up quickly stemming from many of the following:
- Drugs that suppress the immune system that are likely a life-long need after the transplant
- Cost for consultation, evaluation, and testing
- Days of in-hospital treatment
- Fees for specialized transplant physicians
- Lab tests and anesthesia
- Costs for sourcing the organ
- Rehabilitative therapy