Results

Case Settled for Catastrophically Ill Child

Joshua Ramirez is a catastrophically ill child who suffers from a variety of medical conditions. Joshua was born in 1994 with severe handicaps including cerebral palsy, spastic quadriplegia, cortical vision impairment, seizure disorder, questionable hearing, and the inability to speak.

This case was about Humana's improper and cruel termination of Joshua's critical therapy benefits and expulsion from its Medical Care Management program.

Joshua's mother testified that Joshua has between 50 and 100 seizures a day. His condition has not improved over time has never stabilized.

At the time of Joshua's birth, his parents were insured with Humana. Joshua was in Medical Case Management form the time of his birth until August 1998. June Brighton, the Medical Case Manager assigned to Joshua, was very important to Mrs. Ramirez to help coordinate Joshua's case.

At the open enrollment meeting in the fall of 1997, Humana, through its representatives, concealed critical information from the Ramirez family and thereby made false and fraudulent misrepresentations, which induced the Ramirez family to enroll in Humana's HMO plan for the calendar year of 1998. Specifically, Humana failed to disclose to the Ramirez's that Humana had decided to "weed" pediatric cases out of Medical Case Management programs so that it would not have to hire additional case managers to handle the more expensive geriatric cases that were being placed into its Medical Case Management program. The whole focus of case management had moved toward those patients from whom the most savings could be extracted. Humana engaged in this fraudulent scheme of misleading statements prior to the Ramirez family's participation in the plan for the 1998 calendar year and for its own economic benefit and to the detriment of the Ramirez family.

Despite the importance of June Brighton as Joshua's Case Manager, in August 1998, Mrs. Ramirez received a letter from Ms. Brighton advising that Joshua was being terminated from the Medical Case Management program because his condition had stabilized and his goals had been met. Prior to terminating Joshua from Medical Case Management, Humana never contacted Joshua's mother, nor any of Joshua's treating physicians and never reviewed Joshua's medical records.

When Mrs. Ramirez received Humana's letter, she immediately called Ms. Brighton who responded by stating that she was expecting her call. Ms. Brighton informed her that her hands were tied and there was nothing she could do about it. Ms. Brighton said that the orders had come from above and that she was merely acting upon those orders. June Brighton never informed Mrs. Ramirez that Humana's upper management had told her to "weed the pediatric cases out of the medical case management program."

The discontinuation of Medical Case Management made it extremely difficult for Mr. & Mrs. Ramirez to take care of Joshua. As a result of the termination from Medical Case Management and the loss of their Case Manager, the Ramirez's have found it difficult, if not impossible, to get Joshua to the appropriate doctors on a timely basis and on several occasions has had to sit for hours in doctors' offices in order to see their primary care physician just for the simple purposes of getting an authorization to see a specialist or for a prescription drug. In addition, Humana's unilateral termination left Joshua without the ability to get the appropriate therapies. As a result, Joshua's family members, who are not skilled medical professionals, and in spite of their best efforts, were unable to provide the level of care that Joshua so desperately needs. Joshua has suffered as a result. His family has also suffered as a result of his termination from the program. The stress of caring for Joshua gave his parents a tremendous physical and emotional burden.