Playing The HMO Game

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--For years Sol Feldman, 81, of Tamarac, Fla., successfully treated his hypertension with the prescription drug Hyzaar. Then his HMO was sold to another company, and the new plan insisted he use a lower-cost substitute. "I took it for about a week, and my pressure went sky high," Feldman recalls. When the HMO refused to let him go back to Hyzaar, he switched to another plan that covered it. A few months later, however, the new HMO also dropped its Hyzaar coverage. At $79 for a month's supply, Feldman couldn't afford to pay for the prescription on his own. Finally a local doctor took pity on him and provided the tablets free. The HMO's policy remains unchanged.

--When AnnMarie Fischer, 39, of Fort Lauderdale, Fla., gave birth to her daughter Cassie four years ago, doctors discovered the baby had a hole in her heart. Chances were good that Cassie would eventually need surgery to fix the defect if it didn't close on its own. But Fischer, who thought her previous insurance was inadequate, had trouble finding a managed-care plan that would treat her daughter's "pre-existing condition." So she was pleased to discover a local HMO that would, her insurance agent assured her, cover all her child's pre-existing conditions, including the heart problem. But two months later, when doctors determined that Cassie did indeed need surgery, the HMO announced it had a two-year minimum on pre-existing conditions and would not pay for the treatment. The toddler eventually received the care she needed, thanks to a special state program for the indigent.

--Mary Halm, 38, of Chillicothe, Ohio, developed a severe case of endometriosis, in which extraneous uterine tissue permeated her abdomen and left her writhing in pain. Several operations paid for by her HMO failed to remove all the offending tissue. Then her primary-care physician told Halm about a specialist in Atlanta who had developed a novel technique for treating the disease. The HMO refused to refer her, saying there were plenty of specialists in Ohio who could care for her. (Name one, she said. They wouldn't.) Halm appealed the decision for nine months with no response. Finally, no longer able to bear the pain, she borrowed $10,000 and paid for the procedure herself. The operation was a success, and the pain disappeared. But because she had taken matters into her own hands, the HMO won't reimburse her.