Lawsuit says PacifiCare prematurely discharges California patients
A proposed class action lawsuit has been filed against PacifiCare of California for allegedly discharging patients who aren't medically ready to be released from the hospital.
The lawsuit was filed in Los Angeles Superior Court on June 12, 2001, on behalf of the heirs of Monte Radlovic, who was covered at the time of his death under a Secure Horizons health insurance plan issued by PacifiCare as a supplement to Medicare.
"Monte Radlovic should have died from old age, not from sepsis, a serious blood infection caused by untreated and infected decubitous ulcers (also known as bed sores)," the lawsuit charges.
According to the lawsuit — filed by the firm of Shernoff, Bidart, and Darras on behalf of Radlovic's widow and children — Radlovic was repeatedly transferred to nursing and rehabilitative care facilities that offered inadequate care following a broken hip in June 1999.
The lawsuit seeks damages for PacifiCare's alleged failure to provide health benefits under Radlovic's plan, attorneys' fees, punitive damages, and an injunction against "unlawful conduct." Telephone calls to PacifiCare of California seeking comment were not returned.
Besides charges that Radlovic's death was caused by the HMO's denial and delay of his care and by discharging him prematurely from hospitals, the lawsuit alleges that PacifiCare intentionally misrepresented the health plan in marketing materials that induced the senior to enroll in the plan.
According to the lawsuit, when Radlovic signed up for the plan, Secure Horizon advertisements promised (text taken directly from brochures):
- "With Secure Horizons you receive comprehensive medical benefits that go beyond Medicare and promote your total well being."
- "What happens to my Medicare coverage when I join? You will continue to receive all benefits entitled under Medicare, plus you gain additional benefits! When you join Secure Horizons, we become responsible for administering your Medicare benefits. By agreeing to receive all your medical care (except for emergency and out-of-area urgently needed care) through your Secure Horizons contracted Primary Care Physician, you receive all of Medicare's hospital and medical benefits plus additional benefits that Medicare doesn't cover."
- "A wealth of medical benefits for so little cost to you . . . 'Let's see . . . I can get more medical benefits — with virtually no paperwork, no deductibles, and little or no plan premiums or copayments — from one of the premier health care organizations? It sounds too good to be true.' It is true and here's why. . . ."
The lawyers contend that Radlovic believed that his Secure Horizons plan "would live up to its promises and provide him with medical care without any administrative hassle or delay. Unfortunately, Mr. Radlovic was wrong. The true facts were that the defendants did not intend to offer or deliver all the Medicare benefits to which their members were entitled let alone benefits beyond those mandated by Medicare."
|"Monte Radlovic should have died from old age, not from sepsis."|
In addition to the allegations that PacifiCare prematurely released Radlovic from the hospital, the lawsuit also charges that the HMO breached its "duty of good faith and fair dealing" by
- Unreasonably utilizing financial incentives to limit patient care regardless of patients' medical needs.
- Unreasonably making treatment decisions based on the financial concerns of Secure Horizons.
- Unreasonably continuing to accept government premiums from Medicare, while simultaneously refusing to allow Radlovic benefits covered under Medicare.
- Unreasonably failing to disclose to Radlovic that his medical providers were placed in a conflict of interest in that, due to the financial agreements required by Secure Horizons, his medical providers would suffer a financial penalty if they requested, authorized, or obtained care for Radlovic.