17- year-old girl needs liver transplant, CIGNA denies - page 8

Life Denied: Nurses, Family of Sick Teen March on Health Insurance Company Thursday - 17- year-old girl needs liver transplant, CIGNA denies... The family and the nurses are urgently appealing to... Read More

  1. by   Simplepleasures
    Quote from Jolie
    As upopular as this post may be, it is not necessary for the insurance company to prove that the procedure wouldn't have helped this girl. If CIGNA is sued, it will only be necessary to prove that the transplant wasn't covered by her policy. Regardless of the seriousness of an illness or the cost of treatment, insurance companies don't have to pay for what a policy doesn't cover, experimental procedures included.
    You are WAY off here,Cigna will most DEFINATLY have to account for their decision to NOT approve for such a long time, which may have CONTRIBUTED to her death.Geragos is a sharp tough lawyer, you honestly dont think he wont hold Cigna's feet to the fire? This will probably be tried as a wrongful death case, in addition to denial of payment case and some more thrown in for good measure , I suspect. As you usually ask the basis for a posters statement, I will say that my daughter is an attorney, who in the past has done some malpractice cases, this is her view of the way it will be brought to trail. Now I ask you, what did you base your statement on?
    Last edit by Simplepleasures on Dec 24, '07
  2. by   Noryn
    Quote from Jolie
    As upopular as this post may be, it is not necessary for the insurance company to prove that the procedure wouldn't have helped this girl. If CIGNA is sued, it will only be necessary to prove that the transplant wasn't covered by her policy. Regardless of the seriousness of an illness or the cost of treatment, insurance companies don't have to pay for what a policy doesn't cover, experimental procedures included.
    Well I think the big question is, would this be considered "experimental" if the benefits are documented. Again, I only want this to play out in the justice system. Bring the insurance employees and their evidence and let the UCLA doctors present theirs.
  3. by   Jolie
    Quote from ingelein
    Now I ask you, what did you base your statement on?
    I base my statement of knowledge of the law.

    I actually mis-spoke in my previous post. CIGNA, like any defendant in civil court doesn't have to prove anything. The burden of proof in a civil case is entirely on the plaintiff.

    The family will have to prove a number of things in order to prevail in a wrongful death lawsuit against CIGNA, including the following:

    That their insurance policy covered non-experimental transplants.

    That the liver transplant proposed for the girl was non experimental, given her condition.

    That a viable liver was available to the girl to be transplanted in a timely manner.

    That a liver transplant would have saved her life.

    That she wouldn't have died of complications of her leukemia, pneumonia, or the transplant itself.

    I understand that this is an emotional issue, and I share the sorrow expressed by so many that a young girl died an untimely death. I have no doubt that CIGNA will be sued, but filing a lawsuit is not the equivalent of a finding of wrongdoing. The parents' attorney will have to prove the above points, and CIGNA will have the opportunity to defend its actions, based on scientific evidence. As sad as this case is, I believe that CIGNA has science on its's side. Emotion does not equal scientific evidence.
    Last edit by Jolie on Dec 24, '07
  4. by   Jolie
    Quote from Noryn
    Well I think the big question is, would this be considered "experimental" if the benefits are documented. Again, I only want this to play out in the justice system. Bring the insurance employees and their evidence and let the UCLA doctors present theirs.
    I agree.
  5. by   greygooseuria
    How can you say that its wrong for the insurance companies to be for profit, but still get that direct deposit in your checking account every two weeks? Doesn't that make us all "for profit"?
    Uhm. Ok. I am going to try really hard here. First, we work to get paid to support ourselves and our family, not to make a profit. At the end of the year, do you look at your bank account and say "I made $40,000 profit this year!" when most of it went to rent etc? Whereas, for example, Blue Cross used to be nonprofit and was considered successful if it broke even that year. You are making a strawman argument that does not work.

    How much did you hospital or university make last year, and I'm talking profits not revenues?
    I don't care how much my university or hospital made last year, because the last time I remember, I wasn't denied my education or BA after paying for it, and I wasn't denied care when I got into a car accident at 3AM in the middle of winter and had to be taken to the hospital in 6 inches of snow with my broken foot and then have care given all while I didn't have my insurance card on me.

    The reality remains the following:
    Take a closer look at that chart.
    I think you misread the chart. Big numbers=bad.

    Jolie, from what I have seen of documentation of policies where I worked, they are pretty much screwed. Benefits are either experimental or not: new procedures are typically deemed experimental and if there is medical necessity as viewed by her doctors in this case, then the insurance needs to approve as the procedure of giving a transplant is no longer considered experimental in the US. They could have denied it for being not medically necessary, but in this case it was, as NMN criteria is typically met when a doctor bills open heart surgery with a diagnosis of acne.
    Last edit by greygooseuria on Dec 24, '07
  6. by   Jolie
    Quote from jbeau
    Jolie, from what I have seen of documentation of policies where I worked, they are pretty much screwed. Benefits are either experimental or not: new procedures are typically deemed experimental and if there is medical necessity as viewed by her doctors in this case, then the insurance needs to approve as the procedure of giving a transplant is no longer considered experimental in the US. They could have denied it for being not medically necessary, but in this case it was, as NMN criteria is typically met when a doctor bills open heart surgery with a diagnosis of acne.
    That will have to be decided in court. From what I've read, transplantation in an otherwise stable patient would be the standard of care, and not considered experimental.

    Transplanting a liver in a patient with active leukemia and pneumonia is not the normal standard of care, and that is where the determination of "experimental" comes into play. To prove that it is not experimental, the family's attorneys would have to find cases where livers were successfully transplanted into patients with the same complications this girl was experiencing. According to the U of W transplant surgeon quoted earlier in this thread, it doesn't sound likely that they will be able to do so.
    Last edit by Jolie on Dec 24, '07
  7. by   pickledpepperRN
    Why did Cigna approve it after it was too late?

    http://www.youtube.com/watch?v=McGm00Mvakc
  8. by   greygooseuria
    Transplanting a liver in a patient with active leukemia and pneumonia is not the normal standard of care, and that is where the determination of "experimental" comes into play. To prove that it is not experimental, the family's attorneys would have to find cases where livers were successfully transplanted into patients with the same complications this girl was experiencing. According to the U of W transplant surgeon quoted earlier in this thread, it doesn't sound likely that they will be able to do so.
    I think the problem CIGNA is going to come into is that they later approved it during protests. They pretty much screwed themselves. If it were truly experimental, they would not have changed their ruling.
  9. by   Jolie
    Quote from spacenurse
    Why did Cigna approve it after it was too late?
    I think the obvious answer is that they caved to public pressure in a (misguided) effort to avoid negative press.

    Much like malpractice carriers who settle bad baby cases in which the doctor is not at fault, because emotions run high and the public wants to make someone responsible for unfortunate circumstances that could not be prevented or fixed.

    Of course we will not know the reason unless the case goes to trial since privacy laws prevent the insurance company from openly discussing the case, and it would harm their image even more if they were viewed as "attacking" the family.
    Last edit by Jolie on Dec 24, '07
  10. by   HM2VikingRN
    I find it difficult to defend the actions of a multibillion dollar company given the apparent timeline of events.
  11. by   TiredMD
    Quote from HM2Viking
    I find it difficult to defend the actions of a multibillion dollar company given the apparent timeline of events.
    Agreed.

    But I also find it difficult to defend the actions of the doctors who gave this family false hope by offering them a rarely-used procedure for a girl who was very likely going to die regardless of how many organs they wasted on her.

    Am I the only one who wonders if this offer of a transplant was a cynical attempt to avoid having the family sue them after the girl developed life-threatening complications from their original treatment?

    I feel like this was a deeply tragic situation where everyone involved behaved very badly.
  12. by   rph3664
    Quote from TiredMD
    Am I the only one who wonders if this offer of a transplant was a cynical attempt to avoid having the family sue them after the girl developed life-threatening complications from their original treatment?

    I feel like this was a deeply tragic situation where everyone involved behaved very badly.
    I hadn't thought of that, in part because I know of a family where their child had cancer (histiocytosis X) and the treatment cured her cancer but led to liver failure, and she rejected her first liver but as far as I know is still doing well with liver #2 more than 15 years later.

    But she was not receiving cancer treatment when her liver failed! That was long over - when the second nightmare began. She did not leave the PICU for three months, since she rejected the first liver right away and it took that long to find another since kids' livers can't be selected from a vending machine (nor, contrary to popular belief, can adults') and split-liver transplants weren't being done at the time.
  13. by   LiverpoolJane
    i have watched this thread since it was first started and would like to play devils advocate here.

    lets say i am the mother of a 16 year old lying in an icu bed with liver failure and in desperate need of a liver transplant. he hasn't got any other medical problems and is not receiving any other treatment that may interfear with a newly transplanted organ.

    i am called into the hospital as there is a good chance my son is going to theatre tonight as an organ has become available and they are now doing that bloods to see if it is a match.

    hours later i am told that he won't be going after all and the organ has been given to someone else. i later find out that the person it has been given to was someone who was actively recieving a treatment that caused her own liver to fail and could also cause her newly transplanted liver to fail.

    my son dies because another organ does not become available - the one that was transplanted into the young lady was a perfect match to my son.

    what are you going to tell me that will help me understand the reason for your decision.

    thankfully this is not my experience, but i do work in an area were my patients are waiting for kidney transplants - some actually gey a transplant and wish they never had.
    some of our patients have had liver transplants in the past for ald but the anti-rejetion therapy has caused their kidneys to fail.

    i have seen people in desperate need of heart transplants - some die while waiting others get a their transplant and are transformed, but at the end of the day it is rationed and some people will never get an offer of an organ - thats just the way it is.

    please take a moment to consider the person who did receive the liver that would have been a match for this young lady. imagine in a few years time that this recipient, may be getting interviewed on the tv as he has achieved great things and is the picture of health - would you still be thinking it should have been given to the other person??

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