Kaiser Wrongly Denied Coverage, Couple Claims
OAKLAND, Calif. (CN) - Kaiser wrongly denied rehabilitation coverage for a man with a brain injury, he and his wife claim in Alameda County Superior Court.
Scott and Hollie Powell sued Kaiser Foundation Health Plan, Inc., dba Kaiser Permanente, Kaiser Foundation Hospitals and The Permanente Group Inc., for breach of contract, breach of the covenant of good faith and fair dealing, negligence and infliction of emotional distress. Hollie is Scott’s guardian ad litem in the lawsuit.
According to the lawsuit, the Powells bought a business health insurance plan for Galaxie Construction, covering Scott as the owner and Hollie as the bookkeeper and sole employee.
While driving home from visiting an ill friend in June, 2012, Scott Powell, 45, had an intracranial hemorrhage caused by a rare malformation of the connection between arteries and veins in his brain, according to the complaint.
A passerby discovered him unconscious and he was rushed to Kaiser’s Redwood City hospital, where he had emergency surgery, and then "remained unconscious for a period of several weeks. When he awoke, he was paralyzed on the right side of his body, required a feeding tube, and he was unable to communicate,” the complaint states.
In August, he was transferred to a Kaiser skilled nursing facility, the complaint says. He was there about a month, before being transferred to (non-Kaiser) Eden Hospital’s intensive care unit, due to respiratory distress, infections and at least one cardiac arrest, the complaint says.
This was followed by another stint at Kaiser’s Redwood City hospital and then another skilled nursing center, the complaint says.
In late October, Hollie had Scott moved to (non-Kaiser) Santa Clara Valley Medical Center’s brain injury rehabilitation unit, it continues.
There, he had more infections, but once they were controlled he began to make progress, including being able to chew and swallow, the complaint says.
But in December, Kaiser moved him to a third skilled nursing facility, where his condition deteriorated, according to the couple's complaint. He was back at Kaiser’s Redwood City hospital with pneumonia a month later, it says.
Meanwhile, Hollie says she continued her efforts to get rehabilitation for Scott. She made a new request in late December, she says, explaining his need for specific services he could not receive in skilled nursing care.
Kaiser denied Hollie’s request, and she requested an independent medical review through California’s Department of Managed Health Care (DMHC), she says. DMHC called the requested services medically necessary, and Kaiser transferred Scott to its rehabilitation center in Vallejo, the complaint says.
“Shortly after Scott’s transfer to Kaiser Foundation Rehabilitation Center – Vallejo and his commencement of acute rehabilitation, Scott’s therapies were decreased and Hollie Powell was advised that Scott was going to be discharged to a long term care facility because Kaiser did not feel he could meet its standards for rehabilitation improvement,” it continues.
Hollie says she filed a grievance, and Kaiser responded with a denial letter that warned, “If Mr. Powell remains at the Kaiser Foundation Rehabilitation Center in Vallejo, CA, beyond his discharge date, please understand that he might be financially responsible for any expenses incurred.”
This was followed by a “Guarantor Statement,” delivered by certified mail, showing charges of $39,120 for the 12-day period immediately predating Hollie’s grievance, she says.
Hollie requested another independent medical review through the DMHC, but this time DMHC upheld Kaiser’s decision, she says.
In April, 2013, Kaiser transferred Scott to his fourth skilled nursing placement, the complaint says.
That September, Scott was evaluated by a brain injury specialist from a non-Kaiser facility, the Centre for Neuro Skills (CNS), who recommended a CNS-provided rehabilitation program, according to the complaint.
The following March, Hollie requested that Kaiser transfer him to CNS, which Kaiser denied, saying the requested services could be provided by its providers, according to the complaint.
Kaiser told Hollie to schedule an evaluation with its South San Francisco facility’s Physical Medicine and Rehabilitation Department, she says.
Hollie says it took almost four months to get the evaluation scheduled.
“Since the time of the August 6 evaluation and continuing, Kaiser has refused to provide coverage to Scott Powell for a multi-disciplinary acute rehabilitation program at CNS or any other rehabilitation center. Plaintiffs to date have not received a written denial or explanation from Kaiser regarding its determination following the in-Plan rehabilitation evaluation,” the complaint states.
The Powells seek economic and consequential damages, prejudgment interest, attorneys’ fees, witness fees, costs of suit, damages for mental and emotional distress and for pain and suffering, punitive and exemplary damages, non-economic damages and a jury trial. They are represented by Mark O. Hiepler and Maria W. McCarthy of Hiepler & Hiepler in Oxnard.