Supreme Court to Decide If HMO Patients Are Entitled to External Review of Medical Decisions

According to Associated Press articles, the US Supreme Court has agreed to consider a very interesting case from Illinois. Debra Moran is young lady who had been unsuccessfully treated for what her HMO considered Carpal Tunnel Syndrome with physical therapy, drugs, and finally surgery. None of these treatments helped, and by 1997 her arm was totally flail.

Eventually, she found a physician in Virginia who correctly diagnosed her problem as Thoracic Outlet Syndrome and recommended surgical correction. Her HMO gatekeeper, a local primary care physician agreed, but the HMO insisted that she be re-examined by other HMO doctors and they recommended non-surgical management.

Thanks to Illinois State law, she asserted her rights to obtain an independent review from someone who did not work for the HMO. [Forty-one other states have similar legal protection for consumers.] The HMO was eventually forced to agree to the external review, and the independent expert agreed that surgery was necessary. The HMO refused to pay for the recommended operation so the patient paid the $95,000 herself and fully recovered the use of her arm. She then sued the insurance company and won a court decision that forced them to reimburse her for the costs of the surgery.

The HMO then filed suit on the grounds that the Illinois State law is in conflict with Federal law on employee benefits. If the HMO wins, then the patient will have to give back the reimbursement for the costs of the operation. In addition, the legal defense against the HMO litigation cost $142,000 during calendar year 2000 alone, and those costs continue to mount. Thus far, the American Medical Association, the Illinois State Medical Society and U.S. Dept. of Labor have all filed briefs on Moran's behalf.

Watch the national news for the results from "Rush Prudential HMO Inc. v. Moran, 00-1021". You can visit www.medill.nwu.edu for a lay discussion of the case, or for more details on the legal specifics of the case, go to www.harp.org/moran.htm.



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