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Monday, April 17, 2000
UnitedHealthcare files lawsuit against suspension of director
Texas board suspends Dallas HMO's main doctor over case involving nursing care denied to 13-year-old
Associated Press
DALLAS - A Dallas health maintenance organization is challenging the state's suspension of its medical director for denying nursing care to a 13-year-old boy.
The lawsuit, filed last month in a Dallas federal court, has put Texas in the center of a national debate into HMO accountability.
The case focuses on whether UnitedHealthcare's main doctor made the proper ruling in 1998 when he denied nursing care to David Wiser, 13, who suffered from respiratory and other problems.
The child died on Sept. 2, 1998, but the cause of death was a brain aneurysm, not his respiratory problem, said his father, Mark Wiser, 41.
In 1997, the state of Texas became the first to adopt a law allowing consumers to sue their HMOs for damages if they believe that an insurer failed to exercise proper care in its decision-making.
According to doctors and insurers, the Texas Board of Medical Examiners' Feb. 22 suspension of UnitedHealthcare's main doctor is the first in the United States against an HMO medical director, The Dallas Morning News reported Sunday.
Neither United nor its attorney would identify the medical director, but Mark Wiser and a Dec. 23 letter from the state board named Dr. David William Ellis of Dallas. Ellis' job as medical director is to set treatment standards, promote preventive care among physicians, and make final decisions about treatments and procedures for members.
David Wiser had been hospitalized for five weeks beginning in March 1998 because of difficulty breathing.
Before he was discharged from Cook Children's Medical Center in Fort Worth, his doctor recommended that he be placed on a home ventilator and provided with home nursing care "from providers trained in both cardiopulmonary resuscitation and ventilator care."
Ellis denied the recommendation based upon a telephone call with the boy's attending physician and a consultation of two to three hours with United's medical staff, according to the Feb. 22 report.
Ellis determined that the nursing care was custodial in nature, which would not be covered by the insurance plan that the boy's mother had through her employer.
David's nursing care ultimately was provided by his family's secondary insurance carrier, which coincidentally is UnitedHealthcare of California, a sister company of the primary carrier, Mark Wiser said.
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