Last update - 01:20 02/05/2007
Report: Ministry let HMO sue brain-damaged cancer patient
By Ran Reznick
The Clalit health maintenance organization's decision to sue a brain-damaged cancer patient who fought to receive essential medical treatment - a decision that the Health Ministry said was justified - is shocking, wrote Dr. Karny Rubin-Jabotinsky, the health system ombudsman, in an annual report submitted to the Health Ministry yesterday.
"It's impossible not to be shocked and saddened by the fact that the Clalit HMO chose to sue the complainant - a cancer patient who became brain-damaged as a result of the radiation he received, whose ability to defend himself is less than that of the state - without relating to the emotional pressure involved in coping with a lawsuit in general, especially when it involves a person who is sick," the ombudsman wrote.
Rubin-Jabotinsky also fiercely criticized the HMOs for refusing, in several cases, to fund essential treatments for the seriously ill, even though she had ruled that they were legally required to do so. She said these incidents - among the 4,523 complaints filed in 2006, the year covered by the report - demonstrate the need to change the law to make it easier to force HMOs to fund necessary treatments that are included in the health basket of medications and medical treatments covered by insurance.
The report noted that some 22 percent of last year's complaints were found to be justified.
The ombudsman - whose report also sums up her 10 years on the job, in light of her recent departure from the Health Ministry - urged the state to set up an automated system to update the national health insurance program's budget, in place of the current method, in which the budget is negotiated every year.
"The current situation seriously damages the level of public health. It damages the health of all, but particularly of the weaker sectors," she wrote.
Clalit, meanwhile, said that Rubin-Jabotinsky "erred in her analysis" of the cancer patient case and that it had no choice but to follow the procedures forced on the HMOs by a January 2006 amendment to the law initiated by the Health Ministry.
The amendment, which is described at length in the report, marked an important turning point in health insurance regulations by enabling the Health Ministry to force an HMO to finance medical treatments with National Insurance Institute funds designated for that specific HMO. Until then, patients were forced to go to court if their HMOs refused to pay for a procedure, even when the ombudsman had decided that they were required to do so, because the ministry had no way of enforcing its decisions. But few patients actually went to court, wrote Rubin-Jabotinsky, "due to sickness, lack of money and fear of a legal proceeding - and as a result, the insured were prevented from receiving the health services to which they were legally entitled."
Since the amendment was enacted, the HMOs have provided the required medical treatment in 55 cases after the ombudsman threatened to use the law against them, according to the report. Rubin-Jabotinsky said the HMOs generally responded more quickly to the ombudsman's rulings than they did beforehand.
In an unusual move, she also slammed the Health Ministry's administration over the past decade, saying that despite her repeated warnings, it did not allocate sufficient resources to the ombudsman's office - making it difficult for the ministry itself to fulfill its obligation to provide patients with rapid and efficient assistance when their HMOs refused to provide necessary medical treatments.
Some 2,200 of last year's complaints - nearly half the total amount - were about Clalit, the country's largest HMO. There were 502 complaints about Maccabi, 469 about Meuhedet and 412 about Leumit.
Most of the complaints related to the HMOs' failure to provide medications or treatments. Others related to the professional quality of the treatment and administrative problems.