HMO Implant Nightmare: Batteries Not Included

If John Grisham were looking to write about health care reform he might be inspired by a recent federal lawsuit filed in Mississippi against the local Blue Cross & Blue Shield and the Electric Power Association's benefits plan.

The lawsuit provides a window into the chaos created by America's piecemeal insurance market. Workers face an ever-shifting array of health benefits that change each year at open enrollment time as employers shop around for better deals. What's covered in 2008 suddenly may not be in 2009.

Plaintiff Paige Riley, 42, is an extreme example of what can happen as a result. She alleges that Blue Cross & Blue Shield of Mississippi refused to cover an operation to replace the batteries of a stomach-pain device she had surgically implanted in 2005. As a result, Riley had to fork over the $43,364.27 cost in cash.

Riley suffers from gastroparesis, a nasty condition in which the stomach cannot empty itself, causing nausea, vomiting and pain. According to the lawsuit, in 2005 she got a new device from Medtronic ( MDT - news - people ) implanted in her stomach that uses mild electric pulses help relieve symptoms. Called the Enterra, it was approved in 2000 under the FDA's humanitarian device exemption, which is for devices that target a very narrow group of patients.

Her husband's employer, Electric Power Association, covered the first operation and a second operation to put in new batteries in 2007. But by the time Riley needed a third operation to get another set of batteries this spring, Blue Cross & Blue Shield of Mississippi was the plan administrator for the Power Association. It ruled that the Enterra was experimental and refused to cover the new batteries, the lawsuit says. Appeals were denied, according to the lawsuit filed in federal district court in Jackson, Mississippi on Nov. 10.

In looking for help on the Internet, Riley met a Connecticut patient advocate named Jennifer Jaff, who also suffers from gastroparesis. "It's too late for it to be experimental," says Jaff, who connected Riley with her lawyer in Mississippi, Grady "Mac" McCool.

"It's really a straight claim for benefits," says McCool. The lawsuit asks for $43,364.27, the list price that the hospital charged her for the battery replacement, and additional money for pain and suffering and lost income. Representatives for Blue Cross & Blue Shield of Mississippi and the Electric Power Association of Mississippi Group Benefits Trust said that they had not yet been served with the lawsuit and had no comment on it.
 

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