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HIPAA violation? Long story but worth it.

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DCHindley

Junior Member
What is the name of your state (only U.S. law)? Ohio

My wife and I have a bizarre situation that we need legal advice on.

On 5/24/10 9:30am my wife's sister was found by a neighbor sitting on her front steps all dressed for work but very confused and speaking gibberish. Not having our phone number (we had recently moved) she called my SIL's friend around 9:45am. Friend tells neighbor NOT to call 911, arriving around 15 minutes later and saying she would take her to a hospital close to friend's home, but not the closest one. She finally arrives at ER at 10:30am! Friend tells ER she is a friend, but neglects to tell them that SIL has a family history of stroke (mother) or that she also has Lupus (in remission for 20 years), even though she knew this having been a friend for about 30 years. All she gave ER was the fact that SIL had Lasik eye surgery.

About 12:00noon SIL is admitted. Friend finally calls our home phone from SIL's cell phone at 12:30pm. By time my wife can get home from her work and we drive to the hospital it is 2:00pm when we arrive. Sometime within the span between admission and 2:00pm this friend gave the attending neurologist and the nursing staff the strong impression that she was a sister of the patient (she is not). We did advise the nursing station on arrival that my wife is the only sister and only next of kin, but because friend had already given the impression she as a sister, friend remained the point of contact for the hospital staff. We did not know that she had so represented herself. We also advised staff that SIL had Lupus and a family history of stroke, and they certainly acted like this was news to them. At this point they were treating her for a TIA.

A PET scan was ordered before the friend had called our house, but even with this additional info about medical history and Lupus the test was not conducted until around 10:00pm. The physician was advised the test showed a massive ischemic stroke at 12:00pm. He only commences serious stroke treatment then. Around 7:00am on the 25th he calls the friend, still thinking she was a sister, and gives her a very detailed diagnosis and prognosis. My wife arrived, completely unaware of the scan results (the friend never called us) around 9:30 am. When she asked to speak to the physician, the physician seemed to be annoyed, saying he already spoke to her "other sister" that morning and that we should get our info from her.

Well, my wife really tore into the doctor (I walked in myself at that very moment) and set him straight that my wife is the only sister and only next of kin. The doctor was quick to change the contact name & phone to my wife's, and then became extremely nervous. He disappeared for a half hour or so and came back telling us that he had arranged a life flight to a major hospital, nervously pretending to test the SIL's reflexes, lamenting that "If you had brought her in earlier, we could have given her the drug (tPA, which should be given within 3 hours of the stroke) and saved the rest of her brain!"

The treatment at the major hospital was not successful, and SIL continued to have a series of additional strokes. She passed away on 5/27/10. The friend, who had come to the hospital every day since admission, did not come the day she died, having "something to do". A week later, at the funeral, we learn that this friend was the beneficiary of the SIL's employer provided $108,000 life insurance! The SIL had previously told my wife and I, as well as friends and co-workers, that when she dies "everything goes to [our] kids (SIL had no children and her husband and parents had died previously).

We were flabbergasted by this, and both of us immediately thought that this friend might have delayed access to immediate treatment, withheld health history, represented herself as a sister (and possibly gave the physician treatment instructions after that 7am call on the 25th), knowing she would benefit from the SIL's death. The hospital, violating HIPAA by sharing confidential info with a non-relative, and possibly letting this person select treatment options, may have adversely affected her treatment.

Whether the SIL actually named this friend the beneficiary or the friend found a way to change the beneficiary into her name, is an open question. Based on reflection of hints she dropped during the illness and through the day of the funeral, we believe she knew that she was the beneficiary.

We are furious to think this friend may have let my wife's sister die knowing she would receive a large insurance benefit. We have rivaled the claim through the estate attorney and the money is in escrow (I hope), but this going to require litigation to resolve.

What legal recourse do we have available here? The estate (sans insurance) left in trust about $200,000 split among our 2 children. I really don't think the estate attorney is up to the task (he's never had this happen to any estate he has worked with).
 


barry1817

Senior Member
attorney up to case

What is the name of your state (only U.S. law)? Ohio

My wife and I have a bizarre situation that we need legal advice on.

On 5/24/10 9:30am my wife's sister was found by a neighbor sitting on her front steps all dressed for work but very confused and speaking gibberish. Not having our phone number (we had recently moved) she called my SIL's friend around 9:45am. Friend tells neighbor NOT to call 911, arriving around 15 minutes later and saying she would take her to a hospital close to friend's home, but not the closest one. She finally arrives at ER at 10:30am! Friend tells ER she is a friend, but neglects to tell them that SIL has a family history of stroke (mother) or that she also has Lupus (in remission for 20 years), even though she knew this having been a friend for about 30 years. All she gave ER was the fact that SIL had Lasik eye surgery.

About 12:00noon SIL is admitted. Friend finally calls our home phone from SIL's cell phone at 12:30pm. By time my wife can get home from her work and we drive to the hospital it is 2:00pm when we arrive. Sometime within the span between admission and 2:00pm this friend gave the attending neurologist and the nursing staff the strong impression that she was a sister of the patient (she is not). We did advise the nursing station on arrival that my wife is the only sister and only next of kin, but because friend had already given the impression she as a sister, friend remained the point of contact for the hospital staff. We did not know that she had so represented herself. We also advised staff that SIL had Lupus and a family history of stroke, and they certainly acted like this was news to them. At this point they were treating her for a TIA.

A PET scan was ordered before the friend had called our house, but even with this additional info about medical history and Lupus the test was not conducted until around 10:00pm. The physician was advised the test showed a massive ischemic stroke at 12:00pm. He only commences serious stroke treatment then. Around 7:00am on the 25th he calls the friend, still thinking she was a sister, and gives her a very detailed diagnosis and prognosis. My wife arrived, completely unaware of the scan results (the friend never called us) around 9:30 am. When she asked to speak to the physician, the physician seemed to be annoyed, saying he already spoke to her "other sister" that morning and that we should get our info from her.

Well, my wife really tore into the doctor (I walked in myself at that very moment) and set him straight that my wife is the only sister and only next of kin. The doctor was quick to change the contact name & phone to my wife's, and then became extremely nervous. He disappeared for a half hour or so and came back telling us that he had arranged a life flight to a major hospital, nervously pretending to test the SIL's reflexes, lamenting that "If you had brought her in earlier, we could have given her the drug (tPA, which should be given within 3 hours of the stroke) and saved the rest of her brain!"

The treatment at the major hospital was not successful, and SIL continued to have a series of additional strokes. She passed away on 5/27/10. The friend, who had come to the hospital every day since admission, did not come the day she died, having "something to do". A week later, at the funeral, we learn that this friend was the beneficiary of the SIL's employer provided $108,000 life insurance! The SIL had previously told my wife and I, as well as friends and co-workers, that when she dies "everything goes to [our] kids (SIL had no children and her husband and parents had died previously).

We were flabbergasted by this, and both of us immediately thought that this friend might have delayed access to immediate treatment, withheld health history, represented herself as a sister (and possibly gave the physician treatment instructions after that 7am call on the 25th), knowing she would benefit from the SIL's death. The hospital, violating HIPAA by sharing confidential info with a non-relative, and possibly letting this person select treatment options, may have adversely affected her treatment.

Whether the SIL actually named this friend the beneficiary or the friend found a way to change the beneficiary into her name, is an open question. Based on reflection of hints she dropped during the illness and through the day of the funeral, we believe she knew that she was the beneficiary.

We are furious to think this friend may have let my wife's sister die knowing she would receive a large insurance benefit. We have rivaled the claim through the estate attorney and the money is in escrow (I hope), but this going to require litigation to resolve.

What legal recourse do we have available here? The estate (sans insurance) left in trust about $200,000 split among our 2 children. I really don't think the estate attorney is up to the task (he's never had this happen to any estate he has worked with).
If you have doubts about the ability of this attorney, the time to discuss the issue with him, and either get co-counsel or change of counsel is now, before the situation spirals and the costs go out of hand.
 

Dave1952

Senior Member
I don't know what to make of all of the accusations that you toss around. The executor's attorney represents the executor and the estate. The insurance money is not part of the estate. I doubt he will help you. You may wish to discuss your problems with a few attorneys who offer a free initial consult.

Good luck
 

DCHindley

Junior Member
I don't know what to make of all of the accusations that you toss around. The executor's attorney represents the executor and the estate. The insurance money is not part of the estate. I doubt he will help you. You may wish to discuss your problems with a few attorneys who offer a free initial consult.

Good luck
Yes, we do know that insurance is not technically part of an estate, but we were hoping for a little guidance as to where we could go regarding the insurance issue. He has finally agreed to submit it to a "litigator" in their firm (it's a fairly big one), for an opinion. We'll see. That doesn't stop us from looking around as well.

The charges we are makling is driven by a sense of betrayal. Right as soon as I received that 1st phone call, things didn't add up. Why not take her to the local hospital 4 mi away, and not one 11 mi away? "She said she wanted to go there" (we know my SIL hated that hospital for reasons I'll not go into). Why did you just call us now (2 hrs after admissions)? "My (adult) daughter couldn't get through to you because we don't have long distance service" (she was calling me from my SIL's cell phone, which she had access to all along - our number is on the speed dial). When it appeared my SIL was going to die from the stroke, she starts talking about how the SIL's will would be leaving money left to her son and her granddaughter (it did not, estate was left to our children, we think this was a set-up to the eventual revelation that she was an insurance beneficiary). When we changed the locks to her house on the day she died, the friend seemed very distressed and offended. We later found out that the SIL's $4,500 engagement ring from late husband and all the family silverware were missing, so we're sure she took them while SIL was hospitalized, as she had a key nobody had previously knew about, and all other known keys were accounted for. On the same day she died, was going about house claiming items of furniture she felt she was entitled to. Then, the kicker, was finding out she was the beneficiary of a fairly large employer provided life insurance policy (SIL had repeatedly told my wife and me and co-workers that she was leaving "everything" to our children, and usually this means "everything" as most folks don't make those fine distinctions).

So, yes, we are bitter. She used to go on vacations with SIL once a year to photograph baseball players at spring training (it was their hobby, I guess), and go to Toronto for the Phantages Theater offerings another time, so they were in fact friends, but it wasn't always huggy huggy (they didn't have "relationship" or cohabit at any time). The SIL also complained bitterly about this friend's habit of milking welfare, cheating on her taxes, and faking tax returns to refinance a mortgage, so I don't think this beneficiary thing (100%, nothing for burial, etc) was something she would have done. Generally, folks do not leave insurance money to friends, especially when she was very close to my wife and our children. Our estate attorney has never had this happen as long as he has practices (about 20 yrs). We both firmly believe she knew in advance she was a beneficiary (whether by hook or crook). To us, this was cold and calculated negligent homicide on this friend's part.

So sorry to rant, but we cannot get the local police to act. No autopsy and body was cremated, so they don't think that they could prove criminal negligent homicide. We would like to see if we can subpoena the records of the employer and their online benefits administrator for information about what the beneficiary history, including changes, was, and how it was done. The insurer merely responded with screen prints that show who the beneficiary was when she confirmed annual enrollment the previous November. All that tells me is that any change (authorized or unauthorized) to the beneficiary was made before that time. Since the password to her benefits, made when she started her job in June 2006, is our daughter's date of birth, we're pretty sure one or both of our children were originally designated.

I was hoping that by putting pressure on the Hospital (via HIPAA) to state they acted in good faith, but they were misled by the friend into thinking she was a sister (wife says that she actually advised them she was the sister 2 separate times on the day of admission and once immediately after speaking to the rude doctor, before they updated her chart to list her as the primary contact and that she had Lupus and family history of stroke). No wonder the neurologist was sweating bullets and suddenly ordered extraordinary care.

How do I find a good lawyer for something like this? It is, believe it or not, not about the money, it's about principle. We simply are not going to let her benefit from what happened. Is it even necessary to convict her of negligent homicide to have her claim to the benefits negated? She clearly did not act in the SIL's best interest, but her own, by withholding the medical history she definitely knew. It could have made all the difference.

Thanks all.
 
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dadda11o

Member
I don't know that much about the law, but have you informed the insurance company that there appears to be some misrepresentation or fraud by the beneficiary shortly before and leading to insured's death? I don't know how much investigation is done, but if they looked into it and found something, maybe it would take it to the next level from there? If your facts are as presented and you inform them in good faith...I'm certain that payment of benefits falls into HIPAA as an exemption (the company has access to the records without a fuss). Good luck; that would be a nasty "friend" to have.
 

DCHindley

Junior Member
I don't know that much about the law, but have you informed the insurance company that there appears to be some misrepresentation or fraud by the beneficiary shortly before and leading to insured's death? I don't know how much investigation is done, but if they looked into it and found something, maybe it would take it to the next level from there? If your facts are as presented and you inform them in good faith...I'm certain that payment of benefits falls into HIPAA as an exemption (the company has access to the records without a fuss). Good luck; that would be a nasty "friend" to have.
Well, actually we did. The Ins company said "claim denied, info from Georgia Pacific (she worked for National City Bank, now PNC Bank) online benefits system indicates beneficiary was unchanged since date of hire 6/5/2008 (she was hired 6/1/2006)". The estate attorney wrote back that this response with two obvious errors of fact did not instill confidence in the thoroughness of the company's review of the evidence.

They then sent us screen prints of beneficiary information (it was the friend at 100%, not a cent left for burial, etc) as of the dates she last re-enrolled in the employer's benefits system (she did so on two dates in November 2009, the first and last days of the annual open enrollment, making a change to health coverage the second time). This info was sent to us 6 months after she died, after ignoring most of our earlier letters.

They say this "proves" she changed the beneficiary to the friend on those two dates. I say all they showed was that any change was made prior to the earlier of those dates. While our claim was eventually processed, they decided not to make a decision and will leave it to a court to decide.

They were essentially useless. It was Metropolitan Life, by the way.

Dave
 
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csi7

Senior Member
You can have a separate complaint investigation opened with the insurance company through the state agency that oversees the insurance company. The issues raised with the dates of the changes in the beneficiary are valid concerns.
 

DCHindley

Junior Member
You can have a separate complaint investigation opened with the insurance company through the state agency that oversees the insurance company. The issues raised with the dates of the changes in the beneficiary are valid concerns.
Tried to open one with the state bureau of insurance via their web interface, but they never got back to me. And to add insult to injury, I work for the state of Ohio. I guess I'll have to call them directly and be firm. State government can be very bureaucratic, and I may have made my inquiry on the wrong interface (they had 3-4 for different kinds of situations).

Thanks!
 

DCHindley

Junior Member
I think you're out of your mind if you think she will be charged with anything criminal.
From what my internet research is telling me, all that is required (at least I think) is a civil judgement, which is based on preponderence of evidence, and not a criminal conviction, which is based on evidence beyond a reasonable doubt.

This was the reason the police don't think they can do anything unless we can show that the change was either from an IP address other than one linked to my SIL's home or work computer, or was done from home when she should have been at work, etc. Then it is a fraud investigation.

However, I would think that representing herself as a blood relative would be impersonation, a felony. The local police won't refer it to county prosecutors (who are in the middle of their own problems with Prosecutor Bill Mason's ties to Cuyahoga county officials who are either indicted or have already pleaded guilty of corruption).

This is a nightmare.

Dave
 

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