Kaiser Refuses to Pay For Critical Brain Surgery, Suit Claims
By Ramona Young-Grindle
LOS ANGELES (CN) – Kaiser refuses to pay for a man's critical brain surgery to remove an aggressive tumor performed at a non-Kaiser facility, according to a U.S. District Court Central District lawsuit.
Hassan Jaafar sues Kaiser Foundation Health Plan for violations of the Employee Retirement Income Security Act (ERISA), for improper denial of benefits under his employee health care plan and for breach of fiduciary duty.
Jaafar, 58, is a Kaiser Plan member under his employee benefit group health plan sponsored by his employer, United Airlines. The plan is regulated under ERISA.
Jaafar had a seizure while returning from a trip, and a Kaiser neurosurgeon diagnosed an aggressive brain tumor, giablastoma multiforme, after a biopsy. This doctor, Dr. Gabikian, told Jaafar his “only treatment option would be radiation therapy and chemotherapy because based only on the MRI, Dr. Gabikian could tell that any attempted removal of the tumor would leave Mr. Jaafar unable to speak, eat or swallow,” the suit states.
The doctor also said that with treatment he would live about two years, without it, he would die much sooner.
Jaafar says he sought a second opinion at the University of California Los Angeles medical center (UCLA) with Dr. Liau, who said she could safely remove the entire tumor. Dr. Liau wanted brain mapping tests, which Kaiser agreed to pay for, but Kaiser also required Jaafar to meet with another Kaiser neurosurgeon, Dr. Scharnweber.
The tests revealed that the tumor could be removed safely, but that it was growing very quickly and a new branch was approaching Jaafar’s speech center. Surgery was scheduled with Dr. Liau at UCLA four days after Jaafar learned of the test results, according to the action.
The day before the surgery, Jaafar and his wife met with Dr. Scharnweber at Kaiser, as required. Dr. Scharnweber “agreed to push for authorization, noting that UCLA had the resources and technology to do the surgery,” but stressed that follow-up radiation and chemotherapy would have to be at Kaiser.
Later that day, Dr. Gabikian’s nurse called Jaafar’s wife, Houba, and told her that Dr. Scharnweber had decided that he should do the surgery at Kaiser, and scheduled it for a week later. Houba replied that “they had been told that the tumor was growing at such a fast pace that waiting another week was likely to endanger Mr. Jaafar or render the tumor inoperable (as Kaiser had insisted it was until that day).” The nurse then “agreed to try to get authorization from the top chief at Kaiser,” the suit states.
An hour later, Dr. Scharnweber called and told Jaafar’s daughter that he had scheduled the surgery for the following week. When the daughter objected, the doctor said he would push for authorization at UCLA, as he had previously promised to do. According to the suit, Houba also received a phone call a few minutes later with essentially the same message, leaving the family with the impression that authorization would be granted.
Nothing more was heard from Kaiser before the surgery at UCLA the following morning. During the surgery, the family learned that Kaiser had denied the authorization, the suit says. Jaafar says his appeal of the decision was also denied.
Jaafar seeks payment of all benefits due under his health plan, or in the alternative, payment of the costs of the brain surgery as a matter of promissory estoppel (enforceable promise), plus interest and legal costs.
The plaintiff is represented by Lisa S. Kantor of Kantor & Kantor, LLP, in Northridge, California.