Question
What is the name of your state? Oregon
My husband was diagnosed 3.5 months ago, through physicians with our HMO supplementary insurance provider, with esophageal cancer, metastasized to the lymph system -- a Stage IV cancer. We were told this cancer is incurable and that there was no recommended treatment -- no chemo, no radiation, no surgery, nothing! Since that time, we have found several options on our own, which are approved by the FDA, the NIH and the National Cancer Institute. Whole body radio surgery is one of them (done at Georgetown University and at the Cabrini Medical Center in NY), chemo with low-level insulin and more recently a procedure that has been approved since 1998 - PDT - a light activitated chemotherapy. Right here in Portland, OR, this procedure is used for esophageal cancers at all stages by Oregon Health Sciences University, by St. Vincent's and Providence Hospitals and by the Oregon Medical Laser Center, which is located 2 miles from our home. My question, even though we are also covered under medicare, our HMO feels that they are in charge of deciding life and death matters for my husband,so I want to know if it is legal for this HMO to tell us lies about available treatments? Even if the lie is simply an omission of the truth? May a consumer reasonably assume that an HMO keeps up with new procedures or must everyone, after paying these high monthly premiums for 17 years, still be their own best doctor by surfing the net for possibilities? What recourse do we have if this HMO will not refer us to experts outside of their own staff? Can the HMO be forced to pay their share if we can take this up with approved medicare providers?? Since my husband has this pre-existing condition, it is too late to switch HMO's obviously -- or is it? This HMO is Kaiser Permanente, not some small, obscure little group. Aren't there laws in Oregon to protect the consumer from this type of questionable practice?
Answer
You can appeal to patient assistance. HOWEVER while you didn't give your husband's age or other critical health information such as smoking and/or exposure to Agent Orange, most likely the reccommodation was based on several factors and the quality of life your husband might expect following treatment of any sort with this type of cancer at his age.
Answer
If this procedure has only been approved since 1998, it's not impossible that it is still considered experimental. If experimental procedures are not covered (and on most plans they are not) the HMO does not have any obligation to tell you about a treatment they will not cover.
On HMO plans, they are not obligated to refer you to doctors outside the plan, or pay for procedures that are not covered under the plan.
If the procedure is not covered under the plan, no, the HMO cannot be forced to pay for it.