Hilo doctor files suit against HMSA

A Hilo obstetrician-gynecologist is suing the state's largest medical insurance provider, accusing it of intentionally failing to cover certain medications and procedures he considered necessary for his patients.

Hilo attorney Ted Hong filed the civil suit Jan. 21 in Hilo Circuit Court on behalf of Dr. Frederick Nitta, the Hawaii County Medical Society, and patient Charlene Orcino against Hawaii Medical Services Association and HMSA's Board of Directors.

Among the complaint's allegations were that in the cases of 30 patients identified only by their initials in the lawsuit, HMSA rejected Nitta's diagnoses and/or treatments, forcing "each, individual patient/client to go without treatment, or changed the proposed treatment, medical services, procedures, tests, hospitalization and/or medication, to something that did not address their health condition or worsened their health condition."

The suit seeks unspecified damages from HMSA - which was Hawaii's top-earning company in 2018 with $3.2 billion in revenue - and its directors, describing HMSA's withholding of benefits as "racketeering activity."

"This lawsuit is about the doctor/patient relationship," Hong said at a Monday press conference that included Nitta and Orcino. "When you go to see your doctor and he or she recommends a test, a medical procedure or medication, you should be able to rely on his or her training and experience. But insurance company adjusters with little or no medical training are now telling what tests, what procedures and what medication we should get - even though they've never seen us, never looked at our medical history, and wouldn't be able to recognize us if they passed us on the street."

According to the complaint, Nitta prescribed Nifedipine - a drug usually prescribed for high blood pressure or chest pain, but also used to treat preterm labor - to a pregnant Orcino on Jan. 25, 2021. Orcino attempted to fill her prescription at two East Hawaii pharmacies but was told HMSA wouldn't honor Nitta's prescription for Nifedipine.

The lawsuit claims between the time her prescriptions were denied and she had the money to pay for the prescription out-of-pocket, about $200, her conditioned worsened. She was medivaced to Oahu and gave birth at 25 weeks pregnant to a "dangerously premature" son who weighed less than 3 pounds and who "requires significant and regular medical attention based on his developmental challenges."

The suit calls HMSA's refusal to cover the prescription and the ensuing delay "a substantial and contributing factor to the nearly fatal, premature birth" of the infant, Jayson Orcino, and his need for ongoing medical care.

"I was worried," Orcino said, breaking into tears. "What upset me is they didn't do this with my other children. And why deny for this baby, you know? What did he do?"

It's not Nitta's first legal go-around with Hawaii's medical establishment. Since 2015, he's been sued by the state Department of Human Services, has sued the state Department of Health, and in 2019 paid a $1.765 million settlement to HMSA in a billing dispute.

Nitta, who's been a practicing OB/GYN in Hawaii since 1993, said he sought other physicians to join in his suit, but they're fearful of doing so.

"I'm local, born and raised here. I would die for Hawaii," he said. "In the past, it was always bad, but the physicians accepted low pay to stay in Hawaii. We accepted abuse to stay in Hawaii.

"… Why do you think there's a shortage of physicians? Because whether or not you want to or can, how are you going to survive when they pay you $25 a month per patient?

"That's, like, half a tank of gas."

Email John Burnett at [email protected].