Health Net Gives a Boy Access to Specialist Care After Lawsuit
With their 4-year-old son's life at stake, Mark and Kimberly Zembsch filed suit this week against Health Net, contending that the Woodland Hills-based HMO had refused to let the youngster see the one doctor they believe can treat his rare condition.
Jack suffers from metatrophic dysplasia, which causes the spine to twist as its grows, damaging internal organs. The boy lives in Moraga, east of Oakland, but the doctor his parents consider an expert in the disease practices in Delaware.
A spokesman for Health Net, California's third-largest for-profit HMO, said the company had believed that there were local doctors who could perform the surgeries Jack needed.
On Tuesday, the day after the suit was filed amid unflattering news coverage, Health Net said it had learned that local doctors could not handle the case and therefore it would grant the family's long-standing request for a referral.
"Basically our focus has been on trying to get Jack the care he needs," said Dr. Gordon Yenokida, chief medical officer for Health Net. "A rare disease implies that the treatments are rare, but sometimes they are standard."
The case illustrates how the managed-care model of healthcare -- which offers subscribers relatively low premiums in exchange for access to only a limited number of doctors -- could make it difficult for patients who need specialized care. Typically such plans do not allow for care by so-called out-of-network specialists without the insurer's approval.
Glenn Melnick, a Rand Corp. economist and USC professor of healthcare finance, said the Zembsch case was interesting because it brought up the issue of out-of-network care in a public way.
"Usually, they handle these things quietly," he said.
HMO agreements typically require patients to settle complaints confidentially, through regulatory agencies or arbitration. But the Zembsch case became public because under federal law, HMO members who are employed by a church or government -- Mark Zembsch is a deputy city attorney for the city of Berkeley -- can seek remedy through the court system.
In their suit, the Bay Area couple say Jack's spine is twisting at severe and abnormal angles as he grows. He needs surgery as soon as possible to prevent damage to his spinal cord, heart and lungs. He is expected to have 10 to 20 surgeries over his lifetime and without proper care could die young.
