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HMO delay caused permanent injury

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ldevere

Junior Member
California. In September 2005 I got a stress fracture that involved a joint in my foot. At the time, all I knew was I was in pain. I saw my regular MD as required who could not diagnose the problem. She referred me after a couple weeks to an orthopedic generalist. I finally got to see him about 1 month later. Xrays were taken; he poked and prodded and ultimately decided he didn't know what the problem was. Since he was the go-to specialist within the group I petitioned the medical group to see an orthopedic foot specialist outside the group. Since it was urgent, they promised me they would authorize it within 24 hours. I heard nothing from them until two weeks later I received notice that they were going to send me to a podiatrist. I said absolutely not, I wanted to see a REAL doctor. They refused to authorize this. I went to the specialist on my own dime (who did diagnose the problem), but because of the major delays of the HMO group -- 4 months total -- the injury had now caused permanent damage. A grievance was filed with Blue Cross who seems to agree many errors were made. After the fact the HMO group did authorize my seeing this doctor. There is a surgery he can do to repair the damage that was done, but it is major and requires a 5 month recovery period. It's possible I would not be able to work during this time, or only on a limited basis, so I would lose my health insurance, my pay, and possibly my seniority or my job.

Is there a malpractice case here?
 


rmet4nzkx

Senior Member
ldevere said:
California. In September 2005 I got a stress fracture that involved a joint in my foot. At the time, all I knew was I was in pain. I saw my regular MD as required who could not diagnose the problem. She referred me after a couple weeks to an orthopedic generalist. I finally got to see him about 1 month later. Xrays were taken; he poked and prodded and ultimately decided he didn't know what the problem was. Since he was the go-to specialist within the group I petitioned the medical group to see an orthopedic foot specialist outside the group. Since it was urgent, they promised me they would authorize it within 24 hours. I heard nothing from them until two weeks later I received notice that they were going to send me to a podiatrist. I said absolutely not, I wanted to see a REAL doctor. They refused to authorize this. I went to the specialist on my own dime (who did diagnose the problem), but because of the major delays of the HMO group -- 4 months total -- the injury had now caused permanent damage. A grievance was filed with Blue Cross who seems to agree many errors were made. After the fact the HMO group did authorize my seeing this doctor. There is a surgery he can do to repair the damage that was done, but it is major and requires a 5 month recovery period. It's possible I would not be able to work during this time, or only on a limited basis, so I would lose my health insurance, my pay, and possibly my seniority or my job.

Is there a malpractice case here?
Where did the injury occur, on your own time or on the job?
You need to check into how disability works if you anticipate being off on disability following surgery.
Do you qualify for FMLA?
Have you asked for ADA accommodations? You should be able to return to some type of work after surgery at least with an accommodation, since you have been working all this time anyway.
Stress fractures can be very tricky at times especially in joints lke wrists and ankles even Xrays and MRI can miss them, they can heal on their own.
Are you male or female? Age?
Are you a runner or jogger?
Have you made a complaint with the department of managed healthcare http://www.dmhc.ca.gov/
By all means you may consult a personal injury attorney but you will have to be ready to quantify what your loss is and they will review your medical history, because this is not a clearcut case of negligence and the care may be within the standard of care. You will have to have an expert willing to testify that the injury was misdiagnosed based on the evidence in your file. Also you would have to prove that you didn't reinjur or further injur your foot after your initial injury.
 

barry1817

Senior Member
medial malpractice

ldevere said:
California. In September 2005 I got a stress fracture that involved a joint in my foot. At the time, all I knew was I was in pain. I saw my regular MD as required who could not diagnose the problem. She referred me after a couple weeks to an orthopedic generalist. I finally got to see him about 1 month later. Xrays were taken; he poked and prodded and ultimately decided he didn't know what the problem was. Since he was the go-to specialist within the group I petitioned the medical group to see an orthopedic foot specialist outside the group. Since it was urgent, they promised me they would authorize it within 24 hours. I heard nothing from them until two weeks later I received notice that they were going to send me to a podiatrist. I said absolutely not, I wanted to see a REAL doctor. They refused to authorize this. I went to the specialist on my own dime (who did diagnose the problem), but because of the major delays of the HMO group -- 4 months total -- the injury had now caused permanent damage. A grievance was filed with Blue Cross who seems to agree many errors were made. After the fact the HMO group did authorize my seeing this doctor. There is a surgery he can do to repair the damage that was done, but it is major and requires a 5 month recovery period. It's possible I would not be able to work during this time, or only on a limited basis, so I would lose my health insurance, my pay, and possibly my seniority or my job.

Is there a malpractice case here?

Just wonder if those denying you the ability to see a doctor, proper doctor, in a timely manner would have allowed that to happen to them.

If you could show that a two tier level of care existed within the same framework that your policy is, that would be a first step, but otherwise we are dealing with a health care system that is controlled by those who's agenda is different than patients that need to be cared for.
 

rmet4nzkx

Senior Member
barry1817 said:
Just wonder if those denying you the ability to see a doctor, proper doctor, in a timely manner would have allowed that to happen to them.

If you could show that a two tier level of care existed within the same framework that your policy is, that would be a first step, but otherwise we are dealing with a health care system that is controlled by those who's agenda is different than patients that need to be cared for.
THat is why OP was refered to the DMHC, however, the delay may not have been negligence, these breaks are often occult and may not heal well. My son broke his ankle while in war games doing a promotional viedo when he twisted his ankle, 1 year later they discovered it has a hairline fracture still not healed, two surgeries and it is still never going to be the same. THat is the nature of these injuries. If op is a runner or contributed to the injury in some way, their case is going to be difficult as will finding an attorney.
 

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