Minutes Before Surgery, Operation Nixed for Lack of 'Right' Insurance

Doctor and patient tell very different stories of how a hernia procedure got canceled.

Dror (not his real name) had already been seen off by his family, and sat in a sterile robe, hat and shoes, nervously expecting to his hernia surgery to begin at Herzliya Medical Center. At the last minute, Professor Amram Ayalon, the private surgeon whom Dror contacted, informed him that he would not operate.

The reason: Dror did not tap his commercial health insurance. He “activated” his HMO’s supplementary coverage – which would pay the surgeon less.

 “There’s no way to describe the humiliation in getting off of the operating table, taking off the robe, and going back out to family, when the reason for canceling the surgery is about money,” Dror says.

Ayalon has a completely different explanation. “The patient deceived my secretary, and tried to pull one over on me," he says. "This is private medicine, not a public hospital – I’m not obligated to operate on him.”

Logistical questions

This strange story took place roughly a month ago, when Dror showed up for the scheduled operation. The preliminary appointment with the surgeon had taken place two weeks before, at Ayalon's private clinic.

According to Dror, as the appointment was ending, and Ayalon had declared that surgery was necessary, he began asking logistical questions. “He asked me if I had comprehensive care from an HMO, and which one. I told him that I had Clalit. Then he asked if I had additional coverage, and I said yes, but I couldn’t remember through which company – Migdal or Clal. Then he stated that he was obligated to tell me that if I had additional coverage, I had to activate it. I told the professor that I was going to contact them."

A few days before the operation, Dror met with the anesthesiologist, and was asked by the secretary if he had gotten a referral for the operation. Dror answered that he had not done so yet. The secretary told him to check with the surgeon’s secretary, to see if she had already done so for him, and it turns out that she had.

“I didn’t speak to any insurance company – not with Clalit or Migdal – because I was told that they had already done it, that everything was okay, and there was permission for everything,” explained Dror.

On the day of the operation, Dror came to the hospital, was given his file, said goodbye to his wife and went into the pre-op room, where he was fully prepped for the surgery, and dressed in a robe. Then Ayalon came in. “The professor came to my bed, opened the file, and began to flip through it,” said Dror. “He asked, 'Nu, so, Clal or Migdal?’ I told him that I didn’t speak to either company because there was no need, that Clalit covered the cost. He answered me, ‘I’m not a Clalit surgeon. I told you many times that I’m not a Clalit surgeon.’”

Ayalon is actually affiliated with Clalit, but preferred to be paid by Migdal, which pays a much higher amount for the surgery. “He advised me to pay for the surgery myself, then talk to Migdal afterwards,” says Dror. “I refused, and so he refused to operate on me.”

Management left speechless

Dror says that no one was able to explain why the surgery was canceled, given that Clalit had already committed to footing the bill. Dror approached hospital management, which began investigating, and then told Dror that the commitment he got from Clalit should have been enough. “I was told that the professor works with Clalit in general, and specifically regarding my operation,” says Dror. “Hospital management was left speechless, with no explanation for the fact that the operation wasn’t performed, or why Professor Ayalon refused to operate on me.”

Ayalon, for his part, says he does not understand the complaint, arguing that he is the one who fell victim to the patient’s ruse. “He tried to pull one over on me,” the surgeon told TheMarker. “Private insurance companies tell their customers that they should activate their HMO coverage, and in exchange, the private companies pay the patients’ copay, and give other bonuses. I always ask prospective patients what insurance they have, and if they tell me that they have both HMO and private coverage, I always tell them that I operate under the private coverage. This is a private practice, and it’s my right to decide which company I work with,” says Ayalon. Also, the payment surgeons receive from private companies can be three times as high as the fees paid by HMOs.

Asked if it was not a little extreme to take a patient off of the operating table over an insurance issue, Ayalon explained that he doesn't work with HMOs. “I’m not obligated to operate under the framework of HMO coverage. The patient made himself look as if he didn’t understand my secretary, and I told him clearly that I do not operate under comprehensive HMO care, and that I have the right to decide that in a private practice."

Dror vehemently denies that he lied or intentionally tried to use his Clalit insurance. He says he didn’t even realize that in such a case, the surgeon would be paid less.

“The surgeon didn’t see me or my pain, but only the money,” he says. “Even though my insurance was appropriate and he works with [Clalit], he decided he didn’t feel like operating on me, and there’s nothing I can do about it.”

Clalit and the Herzliya Medical Center both confirmed the details of the case.

“An operation was indeed scheduled, and the patient came as he described,” the Herzliya Medical Center said in a statement. “The medical center’s reception office had a referral from Clalit Mushlam” – Clalit’s supplementary insurance program – “to perform the operation. The surgeon’s billing of the insurer is separate from that of the hospital. In a situation where the hospital has a referral from Clalit Mushlam, we schedule the operation and prepare for it, as in this case. But the surgeon is the one who decides on scheduling his patients, and he informed the hospital that the operation had been canceled.”

Health Ministry Director General Prof. Ronni Gamzu said that private hospitals should take steps to prevent such misunderstandings in the future. “Cases like this should be part of the private hospitals’ responsibility," Gamzu said. There could be a case where a person made an innocent mistake, or there was a misunderstanding between him and the surgeon, and I expect the private hospitals to make arrangements to prevent such misunderstandings. The coverage granted by various insurance policies is very complex, and I expect the hospital to take part in arranging this issue.”

AP