Patients Rights Revisited

With coverage decisions by managed care companies potentially skewed by dollars and cents issues, rather than driven solely by medical necessity, 42 states have determined that it is only fair for people to be able to challenge the decisions of their health insurers before an independent third party.

A states right to guarantee claimants such an appeal is not preempted by the Employee Retirement Income Security Act, according to a decision by the U.S. Supreme Court in Rush Prudential HMO v. Moran.

Now that this matter is no longer open to debate, there should be even more pressure put on Congress to level the playing field and clarify any further ambiguities by passing a comprehensive Patients Bill of Rights.

The Supreme Courts decision leaves patients in eight states without the protections from overzealous or unscrupulous managed care administrators accorded to citizens in the other 42. In addition, millions of workers at firms whose health coverage is provided by self-insured employers are not covered by the decision, leaving them at the mercy of their plan managers.

Claimants arent the only ones left hanging by this ruling. Employers will feel the effects as well. Those firms with multi-state operations might have to cope with different benefit mandates in different states–exactly what ERISA was designed to avoid.

Its time to straighten out this mess so that health insurers and employers know exactly what is expected of them. Indications are that employers and managed care firms are resigned to an independent appeals process, but are pleading for one system instead of a hodgepodge of state regulations.

In addition, patients across the country should have the same right to challenge their insurers medical decisions no matter where they live.

Employer, health insurer, and consumer groups need to keep the heat on Congress to stop kicking patients rights around like a political football, and to pass a bill that settles this issue once and for all.


Reproduced from National Underwriter Life & Health/Financial Services Edition, July 15, 2002. Copyright 2002 by The National Underwriter Company in the serial publication. All rights reserved.Copyright in this article as an independent work may be held by the author.