Was Kaiser Permanente correct, or simply trying to save money, when it said Castleman's patient was "hopeless"?

One of Kaiser Permanente's tricks is to avoid testing patients, or to avoid releasing test results, so Kaiser won't have to pay for treatment.

I agree with Plaintiff's claim in the story below that "...a deliberate strategy and business practice on the part of defendants to systematically deny medically necessary care that Kaiser is unable to provide itself...Based on a consistent pattern and practice, defendants routinely deny medically necessary treatment requested by members' medical professionals on invalid and unjustified and unjustifiable grounds for the sole purpose of saving money and, ultimately, cause the premature death of members, thus relieving defendants of the continuing financial obligation to provide care and treatment to desperately ill people."

It will be interesting to find out exactly how Kaiser handled the following case. It is true that some cases are hopeless. But Kaiser's strategies intentionally make it difficult, if not impossible, to know the truth about a patient's condition.

Here's an update on this case.

Man Says Kaiser Business Model Includes Death
By PHILIP A. JANQUART
Courthouse News Service
March 14, 2013

LOS ANGELES (CN) - Kaiser Foundation Health Plan refuses to pay for care necessary to save a man's life, he claims in court.

Jalal Afshar, 58, suffers from Castleman's disease, a rare condition known as lymphoproliferative disorder. The disease is not cancer, according to the American Cancer Society, but often leads to lymphoma and is treated with chemotherapy or radiation. He also suffers from a rare blood disorder that appears along with Castleman's disease, called POEMS syndrome.

Diagnosed in 2005, Afshar says he developed a growth in his abdomen in January 2012 and sought advice from his Kaiser oncologist, Dr. Iman Abdalla, who told him, "I don't know what to do with you," and that she had "run out of ideas and options" for his treatment, the complaint says.

She attributed his difficulty in breathing, edema in his limbs and stomach, and the growth in his abdomen to "middle-age fat" and a "sedentary lifestyle."

He then sought out a second opinion, ultimately traveling to Arkansas where he was seen by Dr. Frits van Rhee at the University of Arkansas in Little Rock. Afshar began receiving chemotherapy on the advice of Dr. van Rhee who also planned to have stem cells collected for a future stem cell transplant. Kaiser, however, denied any coverage of the treatments, claiming Afshar could get the same treatments under the Kaiser plan.

Afshar twice appealed the decision over the phone because Dr. Abdalla had "already admitted that she did not know how to treat him, and given that all of the past treatment Kaiser had offered had been ineffective." Kaiser refused, causing Afshar to return to Los Angeles where doctors administered a 12-hour course of chemotherapy using a combination of drugs that were not the same as the ones used by Dr. van Rhee, according to the complaint.

By June 8, 2012 Afshar's legs were significantly swollen and his breathing had become more labored and difficult, according to the complaint. He developed a fever and his blood pressure dropped, leading to his admittance to the intensive care unit.

On June 13, Afshar's wife Maryam was told by doctors that his condition was "without hope" and that "there was nothing else they could do," according to the complaint.

A chaplain and a palliative care representative then visited Afshar in his room and told him they believed his case was hopeless, according to the complaint.

Afshar, however, refused to accept defeat, returning to Arkansas where he once again began receiving care from Dr. van Rhee. He has since amassed over $1.8 million in medical bills, which Kaiser refuses to pay.

Afshar has been under Dr. van Rhee's care since June 17, 2012.

"This action arises out of a deliberate strategy and business practice on the part of defendants to systematically deny medically necessary care that Kaiser is unable to provide itself," the complaint states. "Based on a consistent pattern and practice, defendants routinely deny medically necessary treatment requested by members' medical professionals on invalid and unjustified and unjustifiable grounds for the sole purpose of saving money and, ultimately, cause the premature death of members, thus relieving defendants of the continuing financial obligation to provide care and treatment to desperately ill people."

Afshar is suing for breach of contract, violations of California's Business and Professions Code and intentional and negligent infliction of emotional distress.

Scott C. Glovsky and Danae A. McElroy, of Pasadena, represent the plaintiff.

Kaiser Foundation Health Plan fails to pay medical bills, yet Kaiser's Rawlings Group goes after patient's settlement with restaurant where he was shot

The Rawlings Group corporate headquarters. The Rawlings Group does collections for Kaiser Foundation Health Plan.

"Defendants' conduct is particularly reprehensible because it was part of a repeated corporate practice and not an isolated occurrence."

See also, "The Rawlings Group plunders its own employees as it plunders Kaiser Permanente Patients"

Click on title of article to see Courthouse News story with link to case documents.

Kaiser Stiffs Hospital, Milks Man for $, He Says
By PHILIP A. JANQUART
Courthouse News
March 5, 2013

LOS ANGELES (CN) - Kaiser Permanente Health Plan failed to pay a man's medical expenses, and then attempted to get its hands on his settlement money, he claims in California Superior Court.

Jesse Cox was shot by a stray bullet while waiting in line at a restaurant drive-thru, leading to a five-day stay at Providence Holy Cross Medical Center in Mission Hills and a $300,000 medical bill that should have been paid by Kaiser, Cox says in his complaint.

Cox subsequently won a $300,000 settlement with the restaurant for failure to provide adequate safety measures for patrons, but alleges that Kaiser is illegally trying to get a big chunk of the dough.

"Not until the end of underlying litigation did defendant Kaiser, by and through its agent and joint venturer, defendant Rawlings, deceptively and unfairly claim a lien and subrogation rights to the proceeds of any settlement in the underlying personal injury action," the complaint states.

The Rawlings Group specializes in healthcare subrogation, or "recovery," services. Cox says Kaiser is using the company to obtain a portion of his settlement.

"Defendant Kaiser, by and through defendant Rawlings, has repeatedly asserted that they are entitled to $100,000 from the settlement proceeds, wholly ignoring the required reduction for costs and attorney fees, despite this being brought to their attention on multiple occasions," the complaint states.

Cox adds that Rawlings "has several times intentionally misled plaintiff's counsel into believing that they were in contact with defendant Kaiser on a regular basis and that their counsel was licensed in California," and that both Kaiser and Rawlings "knew that there was no basis for the claims they were asserting and have utterly failed to provide evidence pursuant to California Civil Code, that defendant Kaiser's lien claim is based upon the reasonable costs of medical services which were [not?] actually paid by any of the defendants herein."

Cox says he has received no proof that Kaiser has paid any of the bill. Under California law, "no lien asserted by a medical group, such as defendant Kaiser, may exceed the sum of the reasonable costs actually paid by the medical group," the complaint says.

Cox says "defendants refused to provide proof of payment actually made because in fact no payment for services was made by any of the defendants herein to any of plaintiff's underlying healthcare providers."

Cox is suing for breach of contract, breach of duty of good faith and fair dealings, fraud and for violation of California's Business & Professions Code. He seeks consequential, general, special, punitive and exemplary damages.

Philip J. Layfield and Jamie L. Keeton of El Segundo represent the plaintiff.