Limits and recourses

Published on

The Orange County Register

A ruling by the California Supreme Court that Medicare-contracted HMO patients can sue their health maintenance organizations doesn’t apply to people who receive their health coverage through a private employer.

But private-sector consumers do have some means of redress, according to Jamie Court, executive director for the Foundation for Taxpayer and Consumer Rights, a California-based, nonprofit education and advocacy organization.

    Q: Can patients who have health coverage through a private employer sue their HMOs?

    A:   In some circumstances. If an HMO denies, delays or modifies recommended treatment and the delay results in significant physical or financial harm, in state court the HMO can be liable for injury.

    Q: When can I sue?

    A:   In most cases, you first must use the independent review process — arbitration — before suing. The Department of Managed Health Care determines whether the claim is subject to the independent review process, which can help you get care when an HMO claims treatment is not medically necessary.

    Q: Is the independent review process always necessary first?

    A:   N o. If substantial harm has occurred before the case can be reviewed or if substantial harm is imminent, you can sue immediately. For example, if you need immediate surgery for which your HMO has denied coverage and without which you may die or be seriously harmed. But you will have to pay for the surgery yourself until the suit is settled.

    Q: What if my plan requires that disagreements be resolved in binding arbitration?

    A: You can sue and recover damages, but only in the arbitration process. But if you are seeking an injunction to stop a plan practice that you feel has harmed you, you may be able to bring a lawsuit in court without going through the arbitration process. For example, if your HMO pays for insulin but not the needles to inject it, you can ask a judge to force the HMO’s hand. Also, if your HMO unfairly administers its arbitration program, such as by delaying consideration of your claim, you can sue.

Consumer Watchdog
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