From the people’s court in the Byron Y. Appleton Honorary Courtroom in Santa Monica.
Patients looking for front office help in securing benefits and interpreting confusing guidelines from insurance companies may be better off reading the fine print themselves.
Ear, nose and throat specialist Sheldon Klausner, M.D., sued former patient Joyce Arrastia and her insurance provider, the Motion Picture Industry Pension and Health Plan (MPIPHP), after the provider refused to pay for Arrastia’s nasal surgery.
The insurance company first gave the go-ahead, but later said they wouldn’t foot the bill for surgery because Arrastia hadn’t received formal authorization and they considered her operation a “nose job,” an assistant to Dr. Klausner told the court.
Arrastia, of Santa Monica, suffered from a deviated septum. Dr. Klausner corrected it without making any changes to Arrastia’s outward appearance.
“There was absolutely no cosmetic surgery performed,” said Arrastia, who was shocked that her insurance wouldn’t pay for the procedure. “Ever since I was a child I’ve had major obstructions in my sinuses.”
Dr. Klausner’s assistant said the insurance providers told her they’d “taken care of it.” But when she sent them the bill for the operation, the MPIPHP refused to pay.
They said they had “no record” of giving the doctor the go-ahead, according to Klausner’s assistant. MPIPHP did not send a representative to court.
After sifting through the fine print, Santa Monica Superior Court Judge Pro Tem Ed Schaffer ruled against Arrastia and the insurance providers for $5,000, the maximum allowable small claims amount, plus court costs.
Judge Schaffer was dismayed by the provider’s failure to keep detailed call logs and by their failure to appear in court.
He asked Arrastia if she had filed a counter-claim against her carrier, indicating that if she had, he could enter judgment solely against the non-appearing defendant.
But Arrastia had not thought to file a formal counter-claim. “I’m sorry,” she told the judge. “I just figured this would all work out (in court).”
Originally published in the Santa Monica Daily Press print edition on October 14, 2002. Read the original PDF.