HMO Approves Boy's Consultation with Specialist

By Cecilia Green

Published on November 08, 2005

After an eight-month battle with the family of a boy suffering from a rare bone disease, Healthnet has agreed to provide coverage for a visit to a specialist. 

Four-year-old Jack Zembsch suffers from an extremely rare bone disease, so rare in fact, that there is only one doctor in the country experienced in treating the disease. Without treatment, Jack will die. However, Health Net, the Zembsch family HMO, would not cover the cost for Jack to visit the specialist, Dr. William Mackenzie.

The prolonged battle with the insurance company prompted the Zembsch family to file a lawsuit. As news of the lawsuit began to spread, people offered their support and even cash donations to help Jack. Health Net responded by agreeing to cover the cost of a consultation with Dr. Mackenzie.

The lawsuit is still pending since the family wants Health Net to agree to cover all procedures that Dr. Mackenzie deems medically necessary. Jack is expected to need 10 to 20 surgeries during his lifetime.

Health Net has agreed to pay for the consultation, but they want to leave the decision of further medical treatment up to the Independent Medical Review and a panel of doctors unassociated with any insurance company.

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