Kaiser Wanted Crash Victim to Call for Pre-Auth, He Says
PORTLAND, Ore. (CN) - Kaiser refuses to pay for emergency services for a man who was severely injured in a motorcycle accident, he claims in a Multnomah County Circuit Court complaint.
Albert Ault was in a motorcycle accident near Burns, Ore. in September 2011, sustaining multiple leg fractures that required surgery to repair. He was transferred from Harney County Hospital to St. Charles Medical Center in Bend, where the surgery was performed.
Ault says he is part of a “Large Group Traditional Copayment Plant” with Kaiser through his job at Pioneer Pump, Inc.
Emergency surgeries and post-surgery care is covered under the policy only if the treating hospital is a participating provider, or Kaiser pre-authorizes care from a non-participating provider.
Kaiser notified Ault following his surgery that it would not cover his medical treatments or his post-surgery follow-up care because St. Charles is not a participating provider under the plan and because Ault did not seek authorization for coverage provided by a non-participating provider.
Ault says it was impossible for him to obtain pre-authorization because of the powerful pain medication he was given before being transferred to St. Charles and that he was only lucid enough to make rational decisions follow his surgery, when the dosage of pain medication was reduced.
“Defendants issued a written denial of plaintiff’s request (to pay the medical bills) on Jan. 17, 2012,” the complaint states. “[It] justifies the denial of plaintiffs claims based solely on the fact that plaintiff was ‘clinically stable’ after being treated at Harney County Hospital, and defendant had not preauthorized plaintiff’s post-stabilization services at St. Charles Medical Center.”
Kaiser explains in the letter that it was “reasonably possible for plaintiff to seek authorization prior to his being transported to St. Charles Medical Center.”
Ault says, however, he was too looped-up on pain medication to even realize he had been transferred to another hospital, much less discuss health plan coverage.
He sued Kaiser Foundation Health Plan of the Northwest, alleging violation of the Employee Retirement Income Security Act. He wants the court to rule the company is obligated to pay his medial expenses, totaling $41,598.42, plus interest, and to award attorneys’ fees.
The plaintiff is represented by Kevin Jacoby and L.G. Billy Dalto in Salem.