Nearly four years after his death, Goodrich has become a symbol of what critics say is wrong with HMOs in America. Attorneys representing his widow, Teresa Goodrich, painted the Goodrichs’ HMO, Aetna Health Plans of California, a subsidiary of Aetna US HealthCare, as a corporation more concerned with its profits than its patients.

The jury fined the country’s largest for-profit HMO more than $120 million for damages. It was the largest amount awarded by a jury against an HMO since managed care became popular in the late 1980s.

Teresa Goodrich, a school teacher, was awarded $116 million in punitive damages on January 20, 1999, four days after the same jury found Aetna liable for compensatory damages of $4.5 million. Goodrich sued Aetna in 1996 for breach of contract and wrongful death, claiming the insurance company refused to approve payment of his treatment. The jury verdict came three years and eight months after David Goodrich, a deputy district attorney in San Bernardino, died in 1995 from a rare form of stomach cancer.

The Appeals Process

Aetna has vowed to appeal, saying the jury was not allowed to hear key evidence that would have shown the company covered what it was obligated to provide, and that David Goodrich was also covered by a second health plan which provided coverage for cancer treatment.

The fact that Goodrich died of cancer is about the only thing on which the two sides agree. A week after the verdict, both sides continue to dispute facts of the case.

Goodrich’s Disease Progresses

According to Teresa Goodrich’s attorney Michael Bidart, David Goodrich’s physicians had told him in June 1992 that he was a good candidate for high-dose chemotherapy and bone marrow transplant, but Aetna did not approve payment of the out-of-network treatment until October.

Typically, HMOs have set fees with hospitals and physicians that provide care to their beneficiaries. Out-of-network treatment is generally not covered by an HMO unless prior approval is granted by the health plan.

"He was told by the surgical oncologist inside his health plan that no one within the plan had experience in treating his form of cancer," Bidart said. "He felt Goodrich needed to go outside, either to City of Hope or to UCLA Medical Center. His request traveled through a maze of utilization review, and it wasn’t until October 5 that he was approved for out-of-town hospitalization."

Aetna officials said David Goodrich was actually approved for out-of-network consultation with a City of Hope oncologist in September, at which time his physicians evaluated whether he was a candidate for high-dose chemotherapy and a bone marrow transplant. Their initial evaluation indicated he was a candidate for this treatment and was scheduled to begin in late October. A CT scan done three weeks before the scheduled treatment revealed his cancer had spread to his liver, said Arthur Liebowitz, MD, chief medical officer for Aetna US HealthCare.

Goodrich’s doctors changed their initial assessment after the metastasis (spread of the disease to other organs) was discovered, and told him they no longer believed he was a candidate for the procedures, Aetna claimed. An outside panel of experts hired by Aetna also concluded that the experimental treatment was not appropriate. Aetna was poised to deny coverage on David Goodrich’s request when his doctors canceled his scheduled treatment, Dr. Liebowitz said.

"By the time we had reached that conclusion, so did his doctors," Dr. Liebowitz said.

Instead, Goodrich underwent traditional chemotherapy in hopes the treatment would reduce his cancer by 50 percent and allow for high-dose chemotherapy in the future. The treatment, however, only prevented the cancer from spreading any further.

Goodrich did not receive cancer treatment until September 1993. After seeing his primary care physician, as required by his health plan, he was recommended for cryosurgery, an experimental treatment that freezes the tumor and area surrounding it in an attempt to shut off blood nourishing the tumor. He underwent the surgery in September at St. John’s Hospital, an out-of-network facility, despite the fact that Aetna had not granted coverage. Late the following month Aetna agreed to pay for that surgery.

Dr. Liebowitz said the late approval was the result of Goodrich first seeking coverage from his wife’s health insurance company. The treatment was initially approved, but later denied because the second insurer was unable to process the claim with Aetna listed as the primary insurer.

A Lengthy Process

A request for coverage was sent to Aetna, but was misplaced, Dr. Liebowitz said. But Goodrich was also covered by a second health plan and was using both plan’s benefits to cover his mounting expenses.

"The jury never heard about the second insurance plan," said Dr. Liebowitz. "They looked at it as if there was no second insurer and that we denied coverage."

By December 1994, Goodrich’s condition was grave and his doctors recommended one more surgery to remove the tumor still in his stomach. "He could hardly eat or drink," Bidart said.

The surgery was performed in mid-January 1995 at St. John’s Hospital, but coverage for the surgery and hospitalization was denied, Bidart said.

According to Dr. Liebowitz, Goodrich requested the second health insurance policy, provided through his wife’s employer, cover the expense of his latest surgery and hospital stay. But because Aetna was listed as the primary insurer, the second health plan was unable to approve coverage until Aetna denied coverage.

"At no point was treatment not carried out," Dr. Liebowitz said. "Mr. Goodrich’s care was directed by his physicians."

Aetna maintains that Goodrich did not maximize his benefits by accepting a nurse case manager to help coordinate his care, which is disputed by Bidart. Aetna officials also vehemently deny contributing to the shortening of Goodrich’s life, citing high-dose chemotherapy is not an appropriate treatment for someone whose disease had progressed as far as his.

Tomorrow: Stinging Verdicts

• Stomach Cancer