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The Honolulu Advertiser

Posted at 11:50 a.m., Thursday, June 20, 2002

Laws that help patients battle HMOs upheld

Advertiser Staff and Wire

WASHINGTON A closely divided Supreme Court today upheld state laws that help patients fight their HMOs, a decision that could increase requests for second opinions.

The court on a 5-4 vote endorsed an effort, like those used in Hawai'i and 41 other states, to let patients bypass health plan gatekeepers who refuse to pay for a treatment. The ruling also lifts some pressure off Congress, which has failed to pass a national patients' rights plan.

The state laws are intended to let people get second opinions, and sometimes force health maintenance organizations to pay up if an independent review shows a surgery or other care is justified.

The Supreme Court said that states, in trying to better arm patients in their battles with big HMOs, did not conflict with a federal law.

In Hawai'i, proponents of patients' rights expressed jubilation about the ruling.

"I'm absolutely delighted," said Dr. Arlene Meyers, president of the Hawai'i Coalition for Health and one of the proponents of the state's four-year-old patients-rights law that allows patients to appeal their cases to the state insurance commissioner. "It means that our patients rights law and appeals process can continue to do its good work."

The ruling comes months after patients rights legislation stalled at the Capitol after the Sept. 11 attacks, putting on hold plans for a nationwide system for independent evaluations. The subject has been part of closed door talks this year, with no consensus.

HMOs had argued that they were not opposed to independent review boards, but wanted one national standard instead of the hodgepodge of state laws.

The Supreme Court upheld the Illinois procedure used by Debra Moran to get her health plan to pay for an operation that fixed her rare, debilitating nerve problem. The surgery cost about $95,000.

The decision focused on whether a 1974 federal law governing most employee benefit plans overrules the state laws on independent reviews.

The court determined it did not, ruling against Moran's health carrier, Rush Prudential HMO Inc., which has been purchased by Wellpoint Health Network.

In Honolulu, attorney Richard Miller recently used the appeals provision to settle a case earlier this year in favor of a man who had been denied coverage for a colon cancer scan by the Hawaii Medical Services Association.

Because the state patients-rights law allows appellants to recover lawyer's fees, Miller said, more patients feel free to challenge HMO decisions. The court's decision to uphold similar laws is welcome, he added.

"This is an important step in balancing consumer right versus the interests of the insurer," said Miller, who serves as a legal consultant to the Hawai'i coalition.

Spokespersons for both HMSA and Kaiser Permanente said the HMOs support independent reviews beyond their own internal appeals processes.

Kaiser spokesperson Jan Kagehiro said Kaiser supported the patients-rights legislation, and Mike Sayama, vice president of health benefits management for HMSA, acknowledged that the ruling could spur more patients to seek second opinions.

"It may be that the coverage that this gets, making it more known to more people, would have that effect," he said. "But the privilege they already have as HMSA members would not be changed (by the ruling."

In Winfield, Ill., a suburb of Chicago, Moran said she hopes the decision encourages other patients to seek second opinions and independent reviews.

They need to know the laws are out there," she said.