Kaiser Will Not Pay for Eye Cancer Care, Patient Claims
9-8-2016 22:50:00

     OAKLAND, Calif. (CN) - Kaiser will not pay for treatment of a rare deadly eye cancer, a patient claims in a lawsuit filed in USDC Northern District of California.

     Trish Giles sued Kaiser Employee Medical Health Plan, Kaiser Permanente Supplemental Medical Plan and Kaiser Foundation Health Plan, Inc., claiming violations of the Employee Retirement Income Security Act (ERISA).
     Under the terms of her plan, Giles is entitled to health care coverage for medically necessary services outside the Kaiser system, she claims in her lawsuit. But after driving Giles away with a “pattern of incompetence and malpractice,” Kaiser refused to pay for her treatment at a facility that specialized in conditions like hers, she claims.
     Giles was diagnosed with sebaceous cell carcinoma, a rare eyelid cancer with a high risk of recurrence and metastasis, in January 2013, according to the complaint. This was almost two years she first saw doctors at Kaiser’s Sacramento facility for drooping eyelids and blurry vision, according to the complaint.
     “Given the rare and deadly nature of the disease, and the difficulty in detection and treatment, it is absolutely crucial that patients with this disease be treated by physicians with specialized expertise in this disease,” the complaint states.
     After Giles was diagnosed, by an ocular pathologist from non-party Washington University, she met with a Kaiser oculoplastic surgeon who suggested she see professionals at non-party Wills Eye Institute in Philadelphia, yet refused to give her a referral to Wills, the complaint continues.
     “Plaintiff was put in a position that if she wanted to pursue medically necessary treatment, she would have to do so out-of-pocket, even though it was obvious that Kaiser was incapable of providing medically necessary treatment for her condition,” the complaint states.
     After two Kaiser doctors agreed that Kaiser did not have the expertise to treat Giles, Kaiser agreed to reimburse her for the two months of treatment she had received, according to the complaint.
     However, when the Wills Institute recommended complete removal of Giles’ eye and cryotherapy, Kaiser insisted that she have it done in-house instead, it continues. The two surgeons Kaiser recommended wanted to only partially-remove her eye and would not authorize cryotherapy, it says. Concerned, Giles requested an expedited referral to the Wills Institute, which Kaiser authorized, but only for the eye removal and one follow-up visit, it continues.
     When Wills doctors did the surgery, they discovered that the cancer had spread, according to the complaint. They recommended radiation therapy and chemotherapy of her sinus cavity and exploratory surgery of her nasal cavity, it says.
     Again, Giles sought a referral to the Wills Institute for this treatment, but Kaiser denied it, according to the complaint.
     Trish Giles claims she was therefore forced to pay hundreds of thousands of dollars out-of-pocket for medically necessary treatment Kaiser was not capable of providing. She seeks declaratory and injunctive relief, reimbursement, attorney’s fees and costs of suit. She is represented by Brian H. Kim of Bolt Keenley Kim in Berkeley.
3:15cv3803