Well Care Denial Of Coverage Causes Woman's Death

Well Care Denial Of Coverage Causes Woman's Death

This case has been set for Trial on Judge Elizabeth T. Maass' trial docket beginning May 12, 2003 through June 13, 2003.

WEST PALM BEACH, FL - (January 9, 2003) Lise Greene was like many Floridians. She believed that if she fell ill her medical insurance provider, Well Care HMO, would be there to cover her medical needs. Mrs. Greene paid her insurance premiums and followed Well Care's rules, regulations, and protocols to the letter. Tragically, Well Care did not live up to its end of the bargain. When Mrs. Greene became sick, Well Care refused to cover her treatment. As a result, Mrs. Greene grew sicker, suffered terribly, and untimely died.

Lise Greene was diagnosed with cancer during various times of her life and underwent radiation and chemotherapy treatment to treat it. The treatment created a condition known as radiation induced hemorrhagic cystitis that thins the walls of the veins and arteries and causes bleeding and clotting in the bladder. Once Mrs. Greene's bleeding began, it caused clotting, which in turn made it impossible for her to eliminate fluids. This condition progressed to the point that it threatened to rupture her bladder.

To alleviate this threat, Mrs. Greene underwent a cauterization procedure that would enable the bladder to function properly. Mrs. Greene underwent six (6) such procedures between January and June of 1998.

Despite these procedures, Mrs. Greene suffered constant pain and discomfort from her condition. To ease the pain, she sought the advice of her Well Care primary care physician, Dr. Craig Prokos, who referred her to a Well Care participating urologist, Dr. James Daughtry.

Dr. Daughtry prescribed hyperbaric oxygen therapy to treat Mrs. Greene. Dr. Daughtry strongly believed that without this therapy Mrs. Greene would continue to suffer, and that she might need an invasive operation to remover her bladder.

Despite Dr. Daughtry's unequivocal recommendation, Well Care refused to cover Mrs. Greene for hyperbaric oxygen therapy. When Mrs. Greene appealed Well Care's denial, they forced her to obtain a second opinion from another Well Care urologist, Dr. Mark Soloway, Chairman of the University of Miami Department of Urology. Dr. Soloway examined Mrs. Greene and concurred completely in Dr. Daughtry's diagnosis of Mrs. Greene and her need for hyperbaric oxygen therapy. Remarkably, Well Care then rejected the prescription of Dr. Daughtry and Dr. Soloway by continuing to deny Mrs. Greene coverage for hyberbaric oxygen therapy.

Well Care denied the therapy based on an industry "cookbook" called the Hayes Directory. Many HMOs like Well Care use the Hayes Directory to justify or deny coverage even though it is principally aimed at saving HMOs costs instead of saving patients' lives and preserving their health.

Well Care never should have used the Hayes Directory to deny Lise Greene treatment for hyperbaric oxygen therapy. In fact, Well Care should never even have consulted the Hayes Directory for answers as to how to cover Lise Greene because Hayes Directory did not even contain her diagnosis. Despite this, Well Care consulted and relied almost exclusively on the Hayes Directory in deciding whether to cover Lise Greene for treatment that two of Well Care's own doctors unequivocally said she should have. By so doing, "Well Care made a conscious decision to put its own profits ahead of the health of Lise Greene", said Mrs. Green's attorney, Theodore J. Leopold.

Following Well Care's wrongful denial of coverage, Mrs. Greene sought an injunction and subsequently a motion for summary judgment stating that Well Care was required to provide coverage for the hyperbaric oxygen therapy.

Due to the delays and her deteriorating condition, however, the Court's favorable rulings on these matters would come too late. Mrs. Greene's condition demanded surgery to treat her bladder. Well Care authorized the surgery to be performed at Jackson Memorial Hospital by Dr. Soloway. "Mrs. Greene's condition was deteriorating daily and this delay as one can easily see caused it to fall into a" do or die" surgery decision," said Mr. Leopold.

Just prior to surgery Well Care contacted Lise Greene directly and advised her that they would not authorize coverage for the surgery unless it was performed by by Dr. D'Angelo at Jupiter Medical Center. Well Care imposed this arbitrary 11th hour condition even though Dr. D'Angelo had previously advised Well Care he was not willing and/or capable of performing the surgery, and that Mrs. Greene's condition was such that the procedure should be performed at Jackson Memorial or some other hospital where other specialists and equipment were more readily available than at Jupiter Medical Center. Ultimately, Well Care forced Mr. Greene to agree to pay the difference between the charges at Jupiter Medical and the charges at Jackson Memorial.

"Based solely on the facts before us, Well Care felt it was better able to determine what doctors were trained and equipped to perform particular procedures rather than the surgeons themselves," added Mr. Leopold.

Surgery was eventually performed in June, 1999, but due in whole or in part to the delay in treatment of her bladder condition caused by the denial of coverage for the hyperbaric oxygen therapy and withdrawal of authorization for coverage for surgery, Lise Greene was unable to survive the surgery and died on June 30, 1999.

Mr. Leopold has filed a seven-count suit on behalf of Gilbert Greene and the memory of his late wife against Well Care in Palm Beach County Circuit Court. The suit requested unspecified damages for breach of contract; breach of implied covenant of good faith and fair dealing; infliction of emotional distress on the late Lise Greene; intentional infliction of emotional distress on Gilbert Greene; and wrongful death amongst other counts.

"Buyer beware", is one of the things we hope to show in this case against Well Care. This company took a woman's life away and they must pay for that. We also would like for consumers who are dealing with Well Care or considering policies with this company to be informed of how they do business when 'paid for coverage' is needed," concluded Mr. Leopold.

Theodore J. Leopold is a partner in the law firm of Ricci~Leopold, P.A. The firm founded in 1982, has six attorneys and is headquartered in West Palm Beach, Florida, with offices located at 1645 Palm Beach Lakes Boulevard. Mr. Leopold may be contacted at 561-684-6500. A copy of the entire law suit filed may be obtained as well as additional information about Ricci, Leopold & Farmer the firm's website at www.riccilaw.com.