Fw: Cosmetic surgery is the example used for exclusions in insurance coverage.

[Guest guest]

> http://www.dallasnews.com/national/430672_patients_29nat.html'>http://www.dallasnews.com/national/430672_patients_29nat.html

>

> Suing in state courts central to patients' rights debate

>

> Plans offer more options for treatment and denied-claim appeals

>

> 07/29/2001

>

> By Anjetta McQueen / Associated Press

>

>

> WASHINGTON - Consumer-friendly. Generous jury awards. That's what state

> courts have become known for - and it's why they have emerged as a

> battleground in Congress over how to hold health plans responsible for

harm

> to people they insure.

>

> Proposals offered by both parties would expand the medical treatments that

> health plans must offer their patients. Patients also would have more ways

> to appeal plans' decisions to deny coverage.

>

> Legislation favored mostly by Democrats would allow patients to pursue

> legal claims for injuries in either federal or state court.

>

> GOP leaders have resisted attempts to push cases into state court. A 1974

> federal pensions and benefits law confines most cases against HMOs and

> other employer-sponsored health plans to federal court.

>

> For now, federal courts are the main venue to sue over denied care that

> results in injury or death. Advocates say patients are blocked from state

> courts, and therefore unable to seek damages for loss of income, pain and

> suffering, or pursue punitive judgments.

>

> " A family loses a loved one and gets turned away from state courts;

another

> patient loses a limb and their case gets heard, " said Fort Worth attorney

> Young, who has sued plans under the Texas law. " Current law

> is just too vague. This is the reason we need a good bill. "

>

> Nine states have laws allowing patients to sue health maintenance

> organizations; several dozen more are considering it. Premiums have risen

4

> percent to 6 percent in most of those states - an insignificant amount,

> advocates say, but too much, according to opponents.

>

> While at least 38 states cap damages in certain cases, opponents worry

> about the instances where states allow unlimited jury awards against a

> single health plan or employer.

>

> Democrats say President Bush's latest designs for patients' rights would

> create a shield for employers looking to deny workers' claims as a way to

> save money.

>

> The president's compromise would steer lawsuits involving HMO care to

> federal courts, but allow some cases to be heard in state courts -

> particularly if they apply to the local medical malpractice laws, said

> sources familiar with the plan, speaking on condition of anonymity.

>

> Mr. Bush and other opponents want to let an independent review panel

> resolve dispute, and worry that would not happen if the Democrats' bill

> becomes law.

>

> Most state laws cannot affect patients in employee-sponsored health plans

> protected by the 1974 federal Employee Retirement Income Security Act.

> Other privately insured people enjoy the full force of the state laws.

>

> Courts have allowed some patients to sue HMOs in state court for

> substandard medical care, such as naming a plan in a malpractice case

> against a doctor.

>

> Yet the ERISA law prevents patients from suing in state court for coverage

> decisions; a plan's stated policy not to pay for cosmetic surgery, for

> example. The bills in Congress would not change that.

>

> Supporters of Texas' patients' rights law and the Democrat-backed plan in

> Congress argue that health plans that agree to cover a treatment in

general

> but reject a doctor's recommendation in a specific case are making medical

> decisions, not coverage decisions based on contracts. Patients in those

> disputes should have the right to go to state court.

>

> " There is no point in giving patients rights and then pre-empting state

> laws designed to enforce those rights, " said Rep. Dingell, D-Mich.

>

>

> ------------------------------------------------------------------------

> Online at: http://www.dallasnews.com/national/430672_patients_29nat.html'>http://www.dallasnews.com/national/430672_patients_29nat.html

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