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Herman Praszkier
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WHO WILL PAY WOMAN'S $750,000 MEDICAL BILL? HMO'S DIFFER

By John G. Carlton
Post-Dispatch Medical Writer

* Diedra Hawkins' employer changed insurance plans. That changed her life.

This much, at least, is clear: Diedra Hawkins had full medical coverage last June when she entered DePaul Health Center in Bridgeton for gallbladder surgery. She should have been in for less than 48 hours. It should have cost around $5,000.

A few months after she got out in September, having spent more than eight weeks in a coma, she had nearly $750,000 in outstanding bills - and letters from two health maintenance organizations refusing to pay them.

Each of the HMOs insisted it was the other's responsibility to pay for Hawkins' care.

Late Friday afternoon, they apparently had a change of heart.

Just before 6 p.m., in a joint statement to the Post-Dispatch, the HMOs offered to cover Hawkins' medical claims. The offer came several months after Hawkins first questioned why her bills had not been paid and several days after the companies were first approached for comment on this story.

Hawkins' attorney, who received the same offer late Friday, described it as "too little too late." He said he could not accept any verbal offer to settle without seeing the details in writing.

Hawkins, 32, and her husband, Charles, 28, are corrections officers for the city of St. Louis. They got into this fix because of something that happens almost every year at many large companies around the country: Their employer decided to switch insurance plans.

Diedra Hawkins' coverage under her old HMO, United HealthCare, was to continue for two weeks after her scheduled surgery. She thought her coverage under the new plan, BlueChoice, would begin immediately after that.

But things worked out very differently. And that's where the argument began.

Among the issues in legal dispute is exactly how Hawkins ended up in a coma. She has filed a malpractice lawsuit.

No one has claimed that Hawkins did not need the operation for painful gallstones. No one has claimed that she failed to get the proper approvals from United HealthCare, which was then her HMO.

No one has claimed that group premiums for St. Louis city employees went unpaid. No one has disputed that someone should have picked up the tab for Hawkins' hospitalization. The $750,000 question is exactly who should pay.

Even with one of the nation's toughest laws protecting patients' rights, Missouri officials say they are powerless to intercede. Instead, the state Insurance Department says it will watch Hawkins' case closely. If it is decided by a judge, it may set a precedent that will force them to write new regulations or seek still stronger laws, the officials say.

Living a nightmare

Diedra and Charles Hawkins say they are living a nightmare of lawyers and loopholes, of bankruptcy and bad luck. And, they say, the same thing could just as easily happen to you.

"If someone came up to me and told me this story, I don't think I would believe it," Diedra Hawkins said not long ago. "The way those medical bills just kept coming, it didn't seem real that you could ever owe that much money. I don't see how we could ever pay it off."

United HealthCare and BlueChoice have offered sympathy for the Hawkinses. Even after their joint statement late Friday, both companies continue to insist they met their contractual obligations to the city.

"We did reimburse all claims for services received while she was a member of United HealthCare," Barbara C. Buenemann, that HMO's chief operating officer, said Thursday.

"This is a very unfortunate, a very unusual situation. In this case, it's really, really clear from our perspective that, when the contract terminated, her coverage terminated, and our ability to pay claims terminated."

"This is a terrible situation," added Michael R. Cardenas, senior counsel for BlueChoice, also on Thursday. "We're trying to work with this lady."

But Cardenas pointed to a provision in his company's contract with the city. It states that only employees who are "actively at work" at the time the contract goes into effect are covered.

Diedra Hawkins was not actively at work on July 1, 1997. She was comatose in DePaul Health Center. Therefore, Cardenas said, she was not covered.

That provision was contained in the request for proposals that invited bids from HMOs for coverage of city employees, he said. It's not in most BlueChoice contracts. If asked, Cardenas said, the company would probably have dropped it from this one.

The Hawkinses might have known about the provision had they only read the booklet describing their BlueChoice benefits.

It's right there, in section 10.2-010. Just below the definition of "accident" and above the definition of "administrative guidelines," the booklet explains what it means to be "actively at work."

Tucked into the 113-word paragraph is this phrase:

"You are also considered to be actively at work on each day of a regular paid vacation or nonworking day on which you are not totally disabled. . . ."

The Hawkinses might have read that section - they might even have understood it - except for the fact that the booklet was not delivered to their home until after Diedra Hawkins' surgery, said their lawyer, Herman Praszkier.

By the time it arrived, Charles Hawkins already had been told the bad news about his wife's operation.

"I remember talking to the nurses," he said. "They told me, `Be strong. She might not make it.' "

Many HMO contracts contain something called a "run-out clause," which allows benefits to be extended to someone who is totally disabled at the time a contract expires. Cardenas said that virtually all Blue Choice contracts contain run-out clauses.

"Had we been in United's shoes," he said Thursday, "she would have continued to be covered."

In fact, if Diedra Hawkins had a traditional health insurance policy - known in the industry as an "indemnity plan" - instead of an HMO, her benefits would have been continued as a matter of state law.

"There is a state statute that controls indemnity insurance," explained Tom Bixby, director of the state Insurance Department's division of consumer affairs. The law requires that health insurance sold in Missouri "provide a reasonable provision" to extend benefits for people who are disabled on the day their insurance runs out.

HMOs are organized under a different law. "It doesn't apply to them," Bixby said.

In January, Hawkins was forced to return to work.

Her doctor had advised her to stay at home until late February, she said, but all her accumulated sick time had been used up. It was becoming increasingly difficult to survive on just one income.

"Stuff was getting turned off," Hawkins recalled. "We'd come home and pick up the phone, and there would be no dial tone. We spent a couple nights at home with no electricity."

On the first day that Hawkins returned to work, she and her husband arrived home to find that his car had been repossessed. The next day, they left for lunch only to discover that Hawkins' car also had been taken for nonpayment.

Meanwhile, the bills continued to arrive at their home.

"They were coming in every day - two or three at a time, six days a week," Charles Hawkins said.

And when he called to ask why his wife's care wasn't being covered, "they told me there wasn't nothing they could do," he said. An HMO billing clerk "told me to take it up with the doctor."

`Pushed to the edge'

Faced with those bills and the repossession of their cars, the Hawkinses filed for bankruptcy earlier this year.

They had to pay repossession fees, and their auto insurance premiums doubled, but at least they got their cars back so they could get to work.

The real irony, Bixby said, is that something like this could happen in Missouri, which has one of the nation's toughest patients' rights laws.

"Here we are, doing much better than almost any other state, and we're still finding problems out there that haven't been addressed," he said.

Bixby had said his department was awaiting a judge's ruling to see if a loophole exists under state law. If the case is settled out of court, there would be no such determination.

State Rep. Tim Harlan, D-Columbia, is one of the authors of that tough Missouri patients' rights law.

"We know we haven't done everything that needs to be done," he said last week.

No matter what an HMO's obligations under the law, Harlan said, "it's not hard to figure out what's the right thing to do."

In their joint statement Friday, the presidents of United HealthCare and Blue Choice repeated that they were under no legal obligation to cover Diedra Hawkins' care.

Still, they said, "both plans recognize that this was an unusual situation that called for an extraordinary cooperative effort."

"From time to time, some individuals may suffer when health coverage transitions from one plan to another," the statement reads. "In this unusual case, our two companies worked together to meet Ms. Hawkins' health-care coverage needs."

Cardenas, the attorney for BlueChoice, said the two HMOs already had been in discussions about the Hawkins case.

"I think it just goes to show that managed care companies can agree and do have a heart," he said.

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