Persistence Wins Out

Persistence Wins Out over HMO

A MARRIED COUPLE had twin boys who were born with a rare heart and lung ailment that can cause dangerous health complications while the boys sleep.

The twins required constant overnight monitoring at home by machines and a nurse. The cost of this at-home care, nearly $150,000 a year, was covered by insurance ever since the boys’ illness was diagnosed when they were six weeks old.

When the twins were seven, their father’s employer switched medical plans. The new insurer, an HMO, determined that the at-home care was no longer medically necessary, and payment for the overnight care stopped.

Attorney William Shernoff filed a lawsuit against the HMO as well as against the company that reviewed medical claims for the HMO.

Shernoff discovered that the doctors retained by the HMO were unqualified to review a case as complicated as this one. None of them had expertise with pediatric heart and lung disease. One of the doctors was a 73-year-old internist who had never even practiced pediatric medicine.

Shernoff furthermore discovered that the review company’s contract with the HMO contained a “savings clause” that created a financial incentive for doctors to deny treatment.

Meanwhile, the twins’ mother wrote to local politicians and newspapers and also appeared on national talk shows to tell her story of how the insurer had disregarded the recommendations of her sons’ personal doctor, a pediatric pulmonologist who had cared for them since birth.

Shernoff’s experience with confronting HMOs and the twins’ mother’s aggressive and indefatigable media campaign resulted in the company’s settling the case out of court. The insurer agreed not only to resume paying for the twins’ nursing care but also to pay more than $1 million in emotional distress damages.