The United States Supreme Court issued an important ruling today that adds support to individual patients’ rights in dealing with HMOs. The decision, in Moran v. Rush Prudential HMO Inc., also supports physician claims that current federal regulations embodied in “ERISA” do not provide blanket protection for the unlawful actions of HMOs.
Debra Moran's HMO, Rush Prudential HMO Inc., refused to approve an operation to treat a painful nerve problem. Ms. Moran sought a second opinion. When the HMO refused to pay for the procedure after an independent review also declared the operation medically necessary, Moran paid the $94,000 in medical cost with loans and credit card advances. The operation was a success and Ms. Moran filed suit against the HMO.
In the ruling issued today, the Supreme Court affirmed the ruling of the U.S. 7th Circuit Court of Appeals in Chicago. The appeal court had earlier found under Illinois law that Moran was entitled to both the review and the reimbursement. The opinion was also an endorsement of similar laws in 41 other states that allow for second opinions and in some situations force HMOs to pay for independent reviews that indicate a surgery or other care is justified. Justice David H. Souter, writing for the majority opinion noted that when an HMO guarantees "medically necessary" procedures as in Ms. Moran’s situation, individual states can allow an independent review of that necessity.
Important to the doctors case against the HMOs was the Court’s indication that, state laws designed to assist patients in their efforts to obtain reasonable healthcare from “for profit” managed care companies, did not contradict the confusing 1974 federal “ERISA” law used by HMOs to defeat state court actions in favor of injured patients and their doctors.
"We are encouraged by this ruling," noted Archie Lamb, lead attorney representing physician plaintiffs in a landmark suit against eight of the nations largest HMOs. "The insurance industry continues to attempt to make unqualified healthcare decisions for patients and their doctors. Decisions that are cost and profit based and are often detrimental to the patient. This ruling is a major setback for that strategy. As representatives of physicians we recognize that this ruling clearly supports the rights of patients to obtain quality healthcare in consultation with those most qualified to assist them; their doctors,” Lamb concluded.
For additional information, please go to www.Miami.com. For the Supreme Court’s opinion please go to www.supremecourtus.gov.
Jamie Court, executive director of the Santa Monica-based
Foundation for Taxpayer and Consumer Rights has authored an article concerning
the HMO’s attack on efforts by the California legislature to protect patient
rights. As noted in the article “[t]he laws have been touted by Gov. Gray Davis
as the toughest in the nation. Kaiser Permanente convinced an administrative law
judge to rule that the state's HMO regulator could not intervene in most
patients' quality of care problems.” Court’s article address the HMOs reaction
to a specific case in which “three patients with ruptured abdominal aortal
aneurysms died after their access to treatment was blocked by Kaiser's
unresponsive telephone call system or its over-capacity emergency rooms.” For
additional details and updates on the weeks activities please go to The
Foundation for Taxpayer & Consumer Rights (FTCR) at www.consumerwatchdog.org