Supreme Court Rules Against HMOs in Patient Rights Case
June 21, 2002
In a judgment aimed at protecting millions of Americans who are insured by health maintenance organizations (HMOs), the Supreme Court ruled Thursday that patients denied coverage by their managed care provider can seek second opinions and enlist independent review boards to assess HMO decisions. The case, Rush Prudential H.M.O. Inc. v. Moran, involved Debra Moran, an Illinois woman whose health insurance provider refused to pay for her expensive and unusual surgical procedure. Rush Prudential also failed to grant her an independent board review. Moran eventually paid for the $95,000 operation herself.
Forty-two states, including Illinois, guarantee patients an outside review when an HMO refuses to pay for a procedure a physician has recommended. The process is not widely used by patients. Advocates hope the Supreme Court's decision to uphold the state's authority will encourage patients to seek outside help when an HMO denies them benefits.
The issue before the Court was whether the 1974 Employee Retirement Income Security Act (Erisa), which pre-empts state laws in regards to employee benefit plans except in state regulation of insurance, overruled the law on independent reviews. In their decision, the justices determined that HMO's "are almost universally regulated as insurers under state law."
Only North and South Dakota, Nevada, Arkansas, Mississippi, Idaho, Wyoming and Nebraska lack regulations allowing for independent review boards.
-- Article Courtesy of InjuryBoard.com
More ...
- Aetna Changing Its Ways
- Managed Care and Insurance Companies / Bad Faith Claims
- Dozens of Lawyers Involved in Lawsuit Against Big HMOs
.