The way of sorrows

Anna Vasilieva

On the 19th of November 1999 the Preobrazhensky intermunicipal court of Moscow was adjudging a claim prosecuted by a citizen Svetlana Gerashenko against the maternity hospital No. 18 and "Oranta-Med", an insurance company. Here is the prehistory of events.

On the 12th of May 1996 Svetlana was hospitalized to the maternity hospital No. 18 with her second child about to be born. The woman’s anamnesis included a very bad eyesight disorder – minus 10 diopters. Natural childbirth could cause retinal detachment and complete blindness. Therefore she had indications for Cesarean section. While still in the maternity house, Svetlana was offered free sterilization, as provided in such circumstances by Point 54 of the Enactment No. 303 of the Russian Ministry of Healthcare. She agreed. Before discharging from the hospital Svetlana was assured that the operation had been successful and she would never to take measures against pregnancy. Nevertheless, three months later she got pregnant again.

I met Svetlana and her husband three years after the events described above. The spouses are still unable to speak of them calmly. When Svetlana started feeling unwell, at first she could not believe that the reason for her dizziness and nausea was a new pregnancy. Just by chance she heard a radio program about a similar incident that had happened abroad. It was a German woman whose undesired pregnancy occurred directly after sterilization. At that moment Svetlana had her first real worries, and she decided to contact her doctors in the maternity hospital. She had to wait two weeks to get the results of the analyzes. Vladimir, Svetlana’s husband, decided to call the hospital himself, because his wife was deeply depressed. That’s the answer he received: "Congratulations, "daddy", your wife is pregnant".

Since that day the woman’s life went on in a kind of pitch darkness. Svetlana recalls that she was dying with despair: cried all days long, fainted several times, was losing her breast milk.

At the same time Svetlana and Vladimir’s relations with the hospital staff were not bad. Even after such a crying medical error the spouses had no plans to conflict with the personnel. Vladimir and Svetlana hoped that the doctors would accept their fault and try to provide efficient medical assistance: terminate the pregnancy and do the sterilization again. But that did not happen. "What hurt us most was that they didn’t even apologize", says Svetlana. All she was offered was to have an abortion when her turn came.

Then Vladimir decided to write to the insurance company, "Oranta-Med", the one that had guaranteed his wife the services included in the Essential Medical Insurance program. Some time later they got an answer signed by "Oranta-Med" Executive Director G.B.Belkina. The letter said that the maternity hospital No. 18 does not belong to the Moscow City Essential Medical Insurance program, therefore they are not competent to insist on this or that medical tactics in the given establishment. Vladimir wrote another letter to "Oranta-Med" asking to make a more detailed approach to their problem, or at least to send the documents which were the base for the refusal. That second letter was simply ignored.

The relationships with the hospital staff kept growing worse. Svetlana had her abortion but she failed to get an appointment to sterilization. Svetlana recalls that time as a very hard period in their life. Vladimir had to excuse himself from work and baby-sit while his wife was waiting in line for her appointment in the hospital. The doctor kept coming late and providing empty talk instead of real help. When the woman was at last appointed to get sterilized, she turned out to have thrush – quite unexpectedly. Svetlana was amazed, she had never felt any signs of infection before. Two days later her younger daughter had thrush aphthae in her mouth. The operation was postponed for an indefinite period of time. Leaping ahead, I have to say that Svetlana has not got appropriate help by this moment. "My hands start trembling at the very thought of going to a gynecologist", the woman complains. She still doesn’t know if a new pregnancy is harmful for her health and how her well-being was affected by the previous operations.

Due to the nervous tension Svetlana developed a cataract of the left eye: she had to have an artificial lens implanted. This time the spouses dealt with a paid clinic, and received quality and efficient help. But still they did not want to leave alone the story with Svetlana’s undesired pregnancy. The spouses started the lawsuit against the hospital and the insurance company. Svetlana believes that it was her civic duty to try and have the negligent workers prosecuted. "We were especially shocked by the doctors’ confidence in their impunity", says Vladimir. "We decided to try and find the way to punish them".

The trial went on for nearly three years. The first medico-legal expertise confirmed that the suitor’s pregnancy happened by the fault of the staff of "No. 18". They used an outdated, ineffective method of sterilization. The hospital contested the experts’ conclusions – their representation of the case history was wrong, and that particular method had to be used for the patient due to her health indications. The case was sent back for reconsideration. The results of graphology expertise showed that Svetlana’s case history contained later erasements. Somebody was trying to make changes to the medical documents that would justify the hospital’s tactics of sterilization. It’s not hard to guess who it was, if you know that for a long time after the suit started the case history was kept by the defendant.

The maternity hospital was found guilty in causing their patient’s moral damage. But the hospital being a budgetary organization, Svetlana was awarded a very modest sum: 10 thousand rubles. This sum will hardly cover the expenses of her health. "Oranta-Med" was not found guilty at all. The spouses were not satisfied with that decision. On the 20th of December the case was reconsidered in the Moscow City Court. But the decision did not change. So Svetlana and Vladimir filed an appeal to the judicial bench of the City Court.

"Anyway, we achieved moral victory", says Svetlana. "I hope that this precedent will shake the doctors’ confidence in their impunity. Of course, we are very tired of these endless suits but we won’t abandon the matter when we are halfway through. My two daughters are growing, and I wouldn’t like them to face the same problems in future".

Svetlana and Vladimir see one of their main tasks in attracting wide public attention to their story. It has already been covered in "Moskovskaya Pravda", "Trud" and "Moskovsky Komsomolets". The spouses will eagerly use their experience to help all women who have found themselves in a similar situation. They believe that it is easier to reach justice together.

Svetlana and Vladimir agreed to have their home phone number and e-mail address published in our journal. We are gladly doing it here: (095) 269-2716. E-mail: petrikovsky@mtu-net.ru

Following the readers' correspondence

The story of Svetlana Gerashenko gives an occasion to speak about a problem which has recently become highly relevant. We are getting many questions from our readers concerning the principles of work of the Essential Medical Insurance System (OMS is a Russian abbreviation). One has to admit that the majority of Russian citizens have a very vague conception of the rights the OMS policy gives them. In our case Svetlana and Vladimir failed to understand why the insurance company that was obliged to protect their interests refused them. I contacted the Deputy Director of the OMS Federal Fund, Nataliya Borisovna Klimova to find out the explanations.

It turned out that many of the state medical establishments do not belong to this insurance system. There is a basic federal program which includes a limited inventory of medical services financed by the OMS budget. The system of Essential Insurance may accept only the clinics that provide the services included in the list. Until recently childbirth and obstetrics were not financed by the OMS budget. But in December 1999 there was a direction to include this group of medical establishments in the Essential Medical Insurance program.

One should point that if territorial OMS funds are able to support the basic program, they have the right to expand the list of services. Thus the Moscow City OMS program has been working with maternity hospitals for several years already. Such inequality of regions is caused by the very structure of earnings of the Essential Insurance programs. Each territorial fund collects insurance premiums from employers in its region. The premium size is 3.6% of the payroll regardless of the form of property. 3.4% of this money stays on the territorial fund’s account, while only 0.2% goes to the federal fund which must use this amount to make even the funding of basic medical programs in different regions. Under such conditions the size of territorial funds’ budget directly depends on the economic well-being of the region. Unfortunately, very few of the funds are self-sufficient, and the rest are constantly under-budgeted.

Unemployed citizens (counting more than 60% of the population, according to the official data) also have the right to use the OMS services. It was supposed that the funds to cover their insurance policies were to come from the budgets of subjects of the Federation. But as shown by the experience of the last six years, they have never reached more than 20% of the planned figures.

There is also a system of interterritorial payments between the funds. Each owner of the OMS policy can receive free medical assistance in any region of the Russian Federation if the service he needs is included in the territorial OMS program. His bill will be then sent to his insurance company. If some medical establishment refuses to fulfill these requirements, one can complain to one’s own insurance company, as well as to the territorial fund this establishment is under.

For any medical establishment to be approved by the OMS system, it should get accreditation and be licensed to provide appropriate medical services. The medical establishments have to meet considerably high demands. They have to be approved by the emidemiologic and fire commissions, the personnel is also to be certified by a commission. If a medical establishment does not answer the norms or its administration refuses to work in the OMS system for some reasons, the fund simply does not pay for its patients, even if they are provided with a service from the OMS list. The establishment keeps working, it is financed from the budget of the Ministry of Healthcare.

This procedure of licensing played its fatal role in the story of Svetlana Gerashenko. In spite of the fact that obstetrics was included in the Moscow OMS program in 1996, the maternity hospital No. 18 was not in the system of essential insurance as it had not got the license for that kind of activity. As for the legal point of view, the refusal of "Oranta-Med" to interfere in the hospital affairs was absolutely competent. Svetlana had only the right to complain to the Moscow Healthcare Committee.

To protect himself from incidents of the like, each policy owner should have detailed information about the ways of the medical establishments whose services he is using. But where can he get this kind of information? To the mind of Nataliya Borisovna, all medical establishments should have the list of free services displayed for everyone to see, along with the addresses of organizations where to send complains of low-quality treatment. The insurance company must also give the client accurate and clear answers to his questions. If a patient has developed any problems in the course of treatment, he can call the insurance company by phone instead of writing a letter. If an insured person has more serious problems, his rights are protected by a special department in each OMS fund.

We will proceed to discuss the problems concerning the Essential Medical Insurance in the next issue. Please send your questions and responses to the address: womplus@mail.ru