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Politics : Politics for Pros- moderated -- Ignore unavailable to you. Want to Upgrade?

To: Lane3 who wrote (15112)	11/4/2003 6:43:02 AM
From: Lane3	Read Replies (2) \| Respond to of 793611

It's interesting how HMOs not paying for something turns into "denial of care." Justices will rule on HMOs Decision on denial of care could prompt flurry of suits By Stephen Henderson KNIGHT RIDDER NEWSPAPERS WASHINGTON - The Supreme Court agreed Monday to consider whether to permit lawsuits against HMOs for denying patients care in what one lawyer calls the "world series" of ongoing litigation over patients' rights. If the justices let two Texas patients seek big-money awards from health-maintenance organizations that denied them drugs and care, it could inspire a wave of lawsuits by patients who feel medically wronged by penny-pinching insurers and probably rekindle the debate over a national patients' bill of rights. "This is the central issue" in the struggle between state and federal regulation of health insurers, said Larry Lorber, a partner at the Proskauer, Rose law firm and an architect of the 1974 Employers Retirement Income Security Act, which governs state regulation of employee benefit plans. "The court has dealt with other insurance-related cases in recent years, but nothing as directly related to coverage issues as these cases. These are as big as any big-ticket cases you'll find." At issue is the extent to which ERISA protects insurers from state-enforced regulations or lawsuits brought in state courts. Soon after ERISA was passed in 1974, the Supreme Court made clear in a series of opinions that states were not permitted to get involved with employer-sponsored health plans, which cover more than 100 million Americans. Patients could sue in federal court to have benefits enforced, and Congress has always been free to establish uniform federal health-care standards. But patients were barred from suing in state courts, where large damages could be awarded. But in recent years, as Congress has failed to act and the shift to managed care has fueled rage over the state of health insurance, lower courts have whittled away at insurers' immunity from state suits. Insurers may not be sued for decisions about the administration of a plan, but they can be held responsible for medical decisions, some courts have ruled. The Supreme Court also has revisited ERISA's restrictions on state regulation and, in an important case last year, said states should be free to force insurers to open their networks to nonmember physicians. In one of the cases the high court will hear, a woman was told by her insurance company that she was covered for only one day of hospitalization after surgery. She sued after she was discharged and developed complications. In the other suit, a man was told his insurance would cover only a generic version of a diabetes drug he needed; he filed suit after the drug caused him internal bleeding. Patients' rights groups have long pointed to such examples as proof of the need for a change in the system. "People should have a recourse when they feel they are improperly denied care," said Ron Pollack, executive director of Families USA, a national patient lobby group. "They don't have the authority and power to contest those decisions. Now that there might be a right to litigate and secure significant damages, the consumer will be in a better position to challenge arbitrary denials of care." But Lorber said Monday that the court could inspire chaos by exposing insurers to liability in state courts. "In each state, you could have different outcomes and different rules," said Lorber, who was deputy assistant secretary of labor for the Ford administration. "The theory behind ERISA was that you shouldn't have 51 standards, which is why it held states back from getting involved. If the court reverses that, you'd really need to get national standards in place to prevent problems." Anthony Knettel, vice president for health affairs at the ERISA Industry Committee, which lobbies for some of the country's largest employers in Washington, said the court needs to address what insurers are doing when they deny coverage for a drug or procedure. "Is the insurer interpreting the terms and conditions of an employee benefit plan, or is it making a medical decision?" Knettel said. The courts have acknowledged before that there are "mixed" decisions that involve both types of considerations, but they have left a gray area that needs defining, he said. Knettel also said that if the court decides to expose insurers to state court liability, the timing could not be worse. "Costs are already spiraling every year, and increased liability is one of the biggest cost drivers," Knettel said. At worst, he said, the costs could go so high as to inspire insurers or employers to reduce the number of people they're willing to cover.

To: Lane3 who wrote (15112)	11/4/2003 7:06:59 AM
From: LindyBill	Read Replies (1) \| Respond to of 793611

And swagger as we do it, for heaven's sake. This seems to really rile a lot of people. Pretty hard to humbly fight a war. It takes a "macho" attitude to be good at it.