Under Illinois law, health maintenance firms must have an independent review procedure in place to resolve disputes over any treatment recommendations to a patient by their primary care physician. The case is reviewed by an unaffiliated doctor chosen explicitly by a patient the primary doctor and the Health Maintenance Organization. In the case that the unaffiliated doctor stated that the service is medically necessary, the organization is required to provide it.
In both cases, the parties involved were insured under ERISA, and when they needed medical attention, their healthcare providers recommended costly treatments. Both parties refused to make payments for their recommended treatment stating that their treatments were not part of their health care plans ( Baker & Logue, 2017) . In the case of Rush Prudential HMO, Inc., v. Moran, Debra Moran was diagnosed with Thoracic Outlet Syndrome, and as a treatment for this condition, Dr. Terzis recommended a complicated surgical procedure. After a review by two of Rush Prudential HMO’s affiliated surgeons, they both settled on a less complicated surgical procedure. The HMO denied Debra coverage for Terzi’s procedure stating that it was medically unnecessary, they were, however, willing to pay for the less complex procedure. Debra opted for the complex procedure by Dr. Terzi leading her to incur a cost of $94,841.27.
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Juan Davila took up an insurance plan offered by Aetna Health Inc. and provided through his employer. His physician prescribed Vioxx to treat his arthritis but his insurance provider Aetna, refused to pay for it. Instead, Davila used Naprosyn which led to him subsequently suffering from a severe reaction which required hospitalization. According to Rosenbaum and Teitelbaum (2004 ), Davilla brought the suit under the Texas Health Care Liability Act (THCLA) with the main argument being that by refusing to cover the services offered, the insurance violated a duty under THCLA to provide ordinary care when making any decisions regarding health care treatment and that such refusals proximately caused the severe injuries.
Both individuals sued in the state court, the ERISA statute, however, prevents courts from hearing the cases. Justice Thomas opinion on this issue was different; he stated that the prevention of review of the health and beneficiary’s claim under the employee benefit plan by the law was not right and termed it as destructive. This ruling was positively received by many since it was seen as a supporting mechanism to help curb the perceived abused of the HMO industry. Justice Thomas dissenting decision played a significant role in the creation of a majority opinion in the Davila case. The supreme courts ruled to protect the rights of patients in employee benefits plans in cases where firms denied them the recommended treatments. Davilla was allowed a review of the health plan wile Aetna Health, on the other hand, compensated him for the hardship he underwent and the costs he incurred.
This decision is a perfect illustration of the complex nature of the American healthcare system. The decision on whether to treat health care coverage simply as coverage and not as a decision about the treatment itself in cases of extraordinary high costs is hard to make. The decision is a good reminder of how essential it is that patients and their physicians should always aggressively pursue appeals of coverage denials in the cases where healthcare is of great importance
References
Baker, T., & Logue, K. D. (2017). Insurance Law and Policy: Cases and Materials . Alphen aan den Rijn, Netherlands: Wolters Kluwer Law & Business.
Rosenbaum, S., & Teitelbaum, J. (2004). AETNA HEALTH, INC. V. DAVILA: IMPLICATIONS FOR PUBLIC HEALTH POLICY. Law and the Public’s Health, 119 , 510-512. Retrieved from oi:10.1016/j.phr.2004.07.009
