Outrage: Man's Health Insurance Is Holding His Liver Transplant Hostage
In January of this year, Dan Reesor, a deputy district attorney in Deschutes County, Oregon, was diagnosed with liver cancer and inflammatory liver disease. Doctors at the University of California Los Angeles told him the combination was fatal, and that a liver transplant is best way to save his life. The liver transplant waiting list has roughly 16,000 people on it, although the sickest are prioritized. But perhaps the greater hurdle to treatment is the financial cost of the procedure: $1.4 million.
As a county employee, Reesor has health insurance. But while Deschutes County is self-insured, it uses an independent administrator, the Montana-based Employee Benefit Management Services, to review claims submitted from employees. EBMS bills itself as “one of the nation’s premier industry leaders in health risk management and third party administration of self-funded health benefit plans, designing strategies to transform the health and wellbeing of individuals, organizations and communities.” Its internal newsletter paints a happy picture of a company that values its employees, works to promote worksite health, and holds a raucous annual client appreciation event featuring, among other things, rafting and rapping.
But EBMS is fundamentally a for-profit entity designed to save its clients money, and in this case the client is Deschutes County. When Reesor approached EBMS about his liver transplant, they flatly denied it, telling him his transplant was both “experimental” and not “medically necessary.” A doctor working for EBMS apparently derived all this from just reading about Reesor; he never met with him. “Basically he's only seen me on paper. So EBMS hires this one doctor who basically determines whether I live or die,” Reesor told local television station KTVZ.
Reesor and his wife Jo are doing everything they can to get the transplant funded. They have set up a website letdanlive.com that seeks to do two things. First, they hope to fundraise with a GoFundMe account; if they can reach $700,000, Reesor will be placed on the transplant list. Second, they are petitioning Deschutes County's three commissioner board members to require the county insurance to cover the transplant. None of the three commissioners replied to request for comment from AlterNet, and have declined to comment to local media.
Dave Doyle, the counsel for the county, told AlterNet in an interview that it is actually county administrator Tom Anderson who has the power in cases of payment dispute (he was unable to discuss this case in particular due to HIPAA regulations). “If certain showing is made with regard to medical necessity, the plan administrator [in this case, Anderson] has the ability to consider that and ultimately make a decision with regard to coverage.” Doyle stressed that “medical necessity” is defined by the plan itself but that Anderson has the ability to decide whether Reesor's condition meets the definition.
There is also the option of suing EBMS for failing to cover the transplant. The Bend Bulletin notes that “In recent years, patients who have had claims denied by the Employee Benefit Management Services have taken legal action in separate cases in locations ranging from Billings, Montana, in 2009 to San Jose, California, in 2008, to Houston, Texas, in 2012. However, all of these cases were dismissed.”
If the county and EBMS do not relent and decide to cover the claim, Dan Reesor's other options are limited. They could make an attempt to apply for Social Security Disability Insurance or quit his job to lower his income to apply for Medicaid in the state. Both are lengthy processes without a sure chance of success.
Dan Reesor has effectively been told that if he is unable to pay, he will die.
Watch local news station KTVZ's report: