Teresa Goodrich v. Aetna U.S. Healthcare of California Inc
Published: Feb. 27, 1999 | Result Date: Jan. 26, 1999 | Filing Date: Jan. 1, 1900 |Case number: RCV020499 – $120,564,000
Judge
Court
San Bernardino Superior
Attorneys
Plaintiff
Michael J. Bidart
(Shernoff, Bidart & Echeveria LLP)
Defendant
Michael B. Bernacchi
(Burke, Williams & Sorensen LLP)
Experts
Plaintiff
Stephen D. Prater
(technical)
Leland Foshag
(medical)
Defendant
Wayne Simon
(technical)
John A. Glaspy M.D.
(medical)
Paul Torrens
(medical)
Facts
This suit was brought by Teresa Goodrich both on behalf of the Estate of her deceased husband, David Goodrich and herself individually. David Goodrich was a career Deputy District attorney for San Bernardino County, who headed up the gang prosecution unit. David had health insurance through his employment with the County of San Bernardino with Partners Health Plan, which later became Aetna Health Plans of Southern California, Inc., and ultimately, the current company, Aetna U.S. Healthcare of California, Inc. David Goodrich collapsed in the courtroom on June 5, 1992, in Department 5 of the San Bernardino Superior Court. After exploratory surgery and testing, David was diagnosed with a rare form of stomach cancer, leiomyosarcoma. David was informed by an Aetna in-plan surgical oncologist that David should be seen at City of Hope inasmuch as no one in-plan had "vast experience" with the disease. The Evidence of Coverage and Disclosure Form issued to David Goodrich for the plan year 1992 did not contain any exclusion or limitations for experimental of investigational procedures. The court ruled that David was vested in the 1992 plan, and that plan governed all David's care following the diagnosis of his disease. The Aetna HMO contracted with Redlands Medical Group, later known as Primecare Medical Group of Redlands, for the utilization review and medical care to be provided to plan members. However, Aetna maintained final authority to approve or deny out-of-plan hospitalizations. The care and treatment of David between June 1992 and his death in March 1995 can be divided into three distinct segments. The first of which was a possible bone marrow transplant in conjunction with high dose chemotherapy to be performed at City of Hope. The second was cryosurgery of the liver with follow up chemotherapy at St. John's Medical Center in Santa Monica. The third was debulking surgery and possible chemotherapy to be performed at St. John' Medical Center as well. In accordance with plan procedure, David sought this primary care physician's referral for medical treatment. His primary care physician issued an authorization for David to be seen at City of Hope. The Utilization Review Department of Redlands Medical Group, in accordance with Aetna procedure under a "Terminal Illness Policy" that was not disclosed to treating physicians or plan members, forwarded the request for treatment at City of Hope to Aetna's local Medical Director, who then sent the request on to Aetna's Home Office in Hartford, Conn. Although the in-plan oncologist's indication was that David needed to go to City of Hope came on July 21, 1992, a response from Aetna was not forthcoming until Nov. 18, 1992, when Aetna issued a denial letter on the basis that "experimental treatment" was not a "covered benefit." There were several interim treatment requests that were denied as being "out-of-plan," "not prior authorized" even though the primary care physician had requested the same. The second major treatment request was on Aug. 26, 1993, when David's primary care physician requested authorization for David to be seen in consultation and possible cryosurgery at St. John's Medical Center. Once again, the UR Department of Primecare Medical Group of Redlands forwarded the request to the local Medical Director of Aetna, who in turn sent the request to the Home Office in Hartford, Conn. It was not until Nov. 3, 1993, when David received a letter from a registered nurse at Aetna indicating that "out-of-plan" services would not be covered. Aetna later paid for majority of the medical bills related to the cryosurgery, but not the follow-up chemotherapy. The third major segment of David's treatment was on Jan. 11, 1995, when his Aetna In-Plan Primary Care Physician requested out-of-plan hospitalization at St. John's for debulking surgery and chemotherapy. *** (FOR CONTINUATION OF FACTS)
Settlement Discussions
The plaintiff made a C.C.P. º998 settlement demand for $_______________ . The defendant made a C.C.P. º998 offer of compromise for $________________ .
Result
Aetna denied that request, one day after David had surgery on Jan. 18, 1995, via a letter of another registered nurse which was delivered to Teresa at the hospital while David was on a ventilator in ICU. Aetna's letter indicated that David would be financially responsible for all charges incurred. David died two months later knowing his wife, a kindergarten school teacher, would be left with the bills. David's treating specialists testified that David was never stable enough following the Jan. 17, 1995, surgery to be transferred to another facility. David died on March 15, 1995, without ever leaving St. John's Medical Center. Following David's death, Teresa sought the help of the primary care physician in appealing Aetna's decision that left her owing approximately $750,000 in medical bills. The primary care physician sent his letter pleading with Aetna to reconsider its position on May 16, 1995. It was not until November 1995, that Aetna responded to the appeal, at which time Aetna upheld its previous decision to deny payment. The plaintiff brought this action against the defendant based on _______________ theories of recovery.
Other Information
The verdict was reached approximately _____ years and _____ months after the case was filed. A settlement conference/ arbitration/ mediation was held on ____/____/19____ before ________________ (name) of _______________ (affiliation) resulting in ______________ . David's treating surgical oncologist, also plaintiff's designated non-retained expert, testified at trial that had he seen David in February 1993, and performed the cryosurgery at that time, he could have extended David's life by approximately 15 to 20 months, and that David would have enjoyed a better quality of life.
Poll
_____-_____
Length
eight weeks
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