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

MBANurse · Dec 24, 2007

My wife is a transplant coordinator... she states that it is VERY unlikely that they in fact had a liver lined up that would have saved her.

Coupled with the fact that she had leukemia; ACTIVE leukemia; that the treatments for destroyed her liver in the first place... why would a transplant agent assign another liver to be; pardon my insensitivity; wasted? It is indeed tragic that the young lady passed away. But if a far better canidate got the liver and lived isnt that a better outcome than both of them dying?

Just my two cents

Patrice13 · Dec 24, 2007

I have been following this forum for a couple of days now. I have a few questions to ask.

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"?

How much did you hospital or university make last year, and I'm talking profits not revenues?

The reality remains the following:

Take a closer look at that chart. We have the best any country has to offer and the only spot that is white is the issue of whether or not patients are getting the right care for their ailments. That is what puts the money issue over the top. We spend almost double because we provide them more care then is necessary which is paid out by the insurance companies. So if you want to cut costs and make a better healthcare system we need the people who can analyze data objectively and allocate resources the way they need to be to be most cost effective and beneficial to our population.

pickledpepperRN · Dec 24, 2007

Girl Denied Healthcare Coverage, Dies; CEO Makes $21 Million

http://sec.edgar-online.com/2007/03/22/0001104659-07-021456/Section16.asp

pickledpepperRN · Dec 24, 2007

Tough calls in transplant case

December 22 2007

...Dr. Goran Klintmalm, chief of the Baylor Regional Transplant Institute in Dallas, said the operation that UCLA wanted to perform was a "very high-risk transplant" and "generally speaking, it is on the margins."

But Klintmalm said he would consider performing the same operation on a 17-year-old and believes the UCLA doctors are among the best in the world.

"The UCLA team is not a cowboy team," he said. "It's a team where they have some of the soundest minds in the industry who deliver judgment on appropriateness virtually every day."...

..."If Cigna could approve the transplant yesterday in response to hundreds of phone calls and people pounding on their door in Glendale, why couldn't they have done it eight days earlier?" said Charles Idelson, spokesman for the Oakland-based group.

Although it isn't clear that Cigna could have saved Nataline by approving the transplant earlier, Idelson said, the insurer should have trusted her doctors.

"The transplant was recommended by the medical professionals at the bedside," Idelson said. "They should have been listened to."...

http://www.latimes.com/business/la-fi-transplant22dec22,1,3777077.story?page=2&track=crosspromo&coll=la-headlines-business

HM2VikingRN, RN · Dec 24, 2007

I have been following this forum for a couple of days now. I have a few questions to ask.
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"?
How much did you hospital or university make last year, and I'm talking profits not revenues?
The reality remains the following:
Take a closer look at that chart. We have the best any country has to offer and the only spot that is white is the issue of whether or not patients are getting the right care for their ailments. That is what puts the money issue over the top. We spend almost double because we provide them more care then is necessary which is paid out by the insurance companies. So if you want to cut costs and make a better healthcare system we need the people who can analyze data objectively and allocate resources the way they need to be to be most cost effective and beneficial to our population.

Ths simple fact is that our health care system ranks SIXTH overall of SIX. The UK ranks second on the "right care dimension" , spends 40% of what we spend and is number one overall for quality. I have looked at this chart several times and the lesson to be taken from this chart is that we can learn quite a bit from other countries about how to make our system work better. If we truly want to make our system the best in the world we would look at what works better in other countries and adopt that for our own system as we work through the redesign.

Quality care- What can the UK teach us?

Safe Care-What can we learn from the Germans?

Coordinated Care- What can we learn from the UK?

Patient Centered care-What can we learn from New Zealand?

Efficiency/Equity-How does the UK differ from us?

Long healthy productive lives-What is Australia doing right?

There are lessons to be learned from the world stage that would be well worth our taking the time to learn and adopt.

Noryn · Dec 24, 2007

I just want to see some credentials here. We have some posters saying these transplant doctors at UCLA (who are likely among the best in the world) are wrong.

It is funny the insurance people claim that before they came to be that there was a ton of waste, yet in the past 20 years look at the overall care in hospitals along with the hospitals that are closing. I wonder how much of it was actually waste. We have lost 3 hospitals I know of in my area in the past 10 years or so.

But again, I want to see these people who denied this claim to be held accountable in a court of law. Let's see what proof the insurance company has that this would not have saved her life.

Jolie, BSN · Dec 24, 2007

But again, I want to see these people who denied this claim to be held accountable in a court of law. Let's see what proof the insurance company has that this would not have saved her life.

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.

Simplepleasures · Dec 24, 2007

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?

Noryn · Dec 24, 2007

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.

Jolie, BSN · Dec 24, 2007

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.

Jolie, BSN · Dec 24, 2007

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.

greygooseuria · Dec 24, 2007

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.