Empire Turns Back

A family wins its battle with an HMO

This story has a happy ending. After almost three years of off-and-on struggle with their HMO, a family's health-care nightmare appears to be over. When asked about the following, er, mix-up—and informed that the Voice would be running an article about it—Empire Blue Cross and Blue Shield changed its mind about a clause the company had previously said exempted it from responsibility for paying more than $100,000 in medical expenses for a 25-year-old's brain surgery.

None of this would have happened without two serious women who sprang into action when their little sister, Mamie C., got sick. During a recent interview in their parents' Murray Hill apartment, Joyce, 30, and Linda, 28, are put together in professional silk and pearls. Mamie, on the other hand, looks frail, sitting on her parents' couch in sweats and socks. The elder sisters clearly dote on her. And, luckily for Mamie, Joyce and Linda are not only devoted sisters, but also, respectively, a doctor and a lawyer.

The family had been loyal customers of Empire Blue Cross and Blue Shield. Mamie's parents first signed on with the company when they moved to the United States from Hong Kong, 28 years ago. And they stayed—paying their bills without incident and rarely using their coverage. They switched to one of Empire's managed care options almost three years ago.

It was around that time that Mamie, then a senior at Barnard, started experiencing strange symptoms: she was lethargic, constantly thirsty, and couldn't recall recent events. Tests, which Empire paid for, soon revealed she had a brain tumor. But in July 1995, shortly after Mamie had a biopsy (the tumor was noncancerous, but growing steadily), the family's policy was terminated, they say, without their knowledge. According to the family, that was because of several administrative errors. Empire responds that it was the result of nonpayment. The policy was eventually reinstated—but only after Mamie's mother launched a phone campaign. Barbara would stand behind English-speaking friends, instructing them in Chinese about what to say.

Then, last year, Mamie's family's membership in the HMO was once again mysteriously terminated. According to the family, the November bill from the company didn't arrive. Mamie's mother called several times to report the missing bill and request another, but the company did not replace it, nor did it send a bill for December. Empire says it has no record of the calls. The company also says it sent a letter terminating the policy, again for nonpayment, at around this time, but the family says it never came. Barbara says she visited the office in person to try to pay the premiums for November and December, but says an Empire worker told her to wait until the bills arrived in the mail. Eventually she wrote a check covering the missing invoices and, the family says, was assured by an Empire staffer that the policy would continue uninterrupted and any future surgeries would be paid for.

So when Mamie required urgent surgery to remove the brain tumor this February, the family assumed that they were covered. According to the family, social workers at Mount Sinai, where the surgery was performed, contacted the HMO to make sure that the family's policy was in order. And after Mamie was released from the hospital, Barbara even received a statement from Empire saying that the company would pay for the nearly month-long hospitalization and surgery—which cost more than $100,000. But five weeks later, the family says, Empire sent another notice that it was refusing to pay Mamie's bills. The reason: Because the family's membership in the HMO had been stopped and then restarted, Mamie's tumor was now considered a preexisting condition that wouldn't be covered.

In her courteous way, Joyce, who, with Linda's lawyerly help, wrote a friendly yet firm complaint to Empire, was willing to consider that the company's foul-ups were merely a matter of bad luck. "It could just be an administrative error," she mused delicately in the interview. But even the decorous doctor allowed some suspicion to creep into her reading of the mix-up. "It does seem so coincidental," she admitted, "all these situations occurring at the same time, when we need the coverage most, after 30 years without problems."

Whether in fact it was a matter of greed or just unfortunate coincidence, the insurance lapse left the family members in a variety of awkward positions. Linda and Joyce have become the family's official liaisons with the health-care world, while their mother supervises in Chinese. (Their father, who sleeps through the interview slumped in an armchair with a newspaper across his chest, works six days a week in his Chinatown bakery.)

Linda, whose current job involves "lots of paperwork" and no litigation, spent many hours researching the family's legal options and steeling herself for the battle that appeared to loom.

Joyce, who did her OB/GYN residency at Mount Sinai, felt increasingly uncomfortable around the former coworkers who had cared for her sister and still had not been paid. The family even skipped appointments to avoid some of those doctors. "Mamie really should have followed up with the neurosurgeon once or twice already," said Joyce, "but we can't go to see him because we're embarrassed because her bills aren't paid."

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