WASHINGTON – The Supreme Court (search) said Monday it will settle a fight over patients' rights (search) in court when their HMOs (search) refuse to pay for recommended medical treatment, an issue at the heart of the long debate over efficiency versus service in managed health care.
The case involves an issue that has stymied Congress, which has tried and failed to pass national patients' rights legislation. Some states have passed their own patient protection laws, but the question of where patients can sue and what they can ask for in court is still unresolved.
For patients, the court's answer could determine whether they can win large amounts of money in court if health insurers refuse to pay for beneficial or even lifesaving treatment.
If the court sides with insurers, it would mean that state courts, and the potential they offer for large damage awards from juries, would be off limits for most negligence or malpractice suits against HMOs.
Lower courts have divided over the question of whether federal law allows the kind of negligence or malpractice suit at issue in this case.
The court agreed to hear two appeals, one from a patient and one from an insurer. The patient is a Texas man whose insurer required him to try a cheaper alternative to the painkiller Vioxx, which his doctor had prescribed for arthritis. Juan Davila claims the cheaper drug caused bleeding ulcers and almost caused a heart attack. Davila ended up in the emergency room in 2000, where he says doctors told him he was hours away from bleeding to death. Davila recovered but can no longer take any pain medication that is absorbed through the stomach.
Davila sued his health insurer, Aetna Health Inc. (AET), for negligence. He sued in Texas courts, under a state patient protection law.
In the second case, Cigna Healthcare (CI) appealed in a case involving a Texas hysterectomy patient who claimed she was kicked out of the hospital after one day. Ruby Calad's doctor had recommended a longer recovery. Calad said she suffered complications that landed her in the emergency room a few days later.
Insurers claim that a 1974 federal law governing employee benefit plans trumps state patient protection laws or other state laws that allow medical negligence suits in local courts.
Lower courts are divided over the reach of the 1974 law, which requires that disputes over benefits be resolved in federal courts. The Supreme Court has previously ruled some kinds of lawsuits out of bounds in state courts, where damages are generally higher.
At issue now are lawsuits over a large gray area where decisions about treatment and insurance coverage mingle. In most such cases, a doctor affiliated with an HMO recommends one thing but HMO administrators reject the request because the treatment is not covered by the plan. The administrators may recommend something else instead.
The Davila and Calad cases are typical of what happens next.
In both instances, insurers claimed the original lawsuit belonged in federal court because the claim could have been brought under the 1974 law, the Employee Retirement Income Security Act (search) or ERISA. Once the suit was moved to federal court, the insurer asked that it be dismissed because it was an improper lawsuit under ERISA.
ERISA allows suits to permit a patient to get a particular benefit that the plan has denied, but not patient lawsuits for monetary damages. The law predates the rise of managed care, and lawyers and judges have called for an overhaul.
Employer-sponsored health insurance covers nearly 160 million people now in the workforce and their families, as well as 16 million retirees, according to court filings in a related lawsuit.
As of 2001, 93 percent of employees with employer-sponsored health plans were enrolled in some kind of managed care.
The cases are Aetna Health Inc. v. Davila, 02-1845, and Cigna Healthcare of Texas Inc. v. Calad, 03-83.