The Privatization of Health Care Reform: Legal and Regulatory Perspectives

By M. Gregg Bloche | Go to book overview

4
THE MANAGEMENT OF CONFLICT OVER
HEALTH INSURANCE COVERAGE

Gerard F. Anderson

Mark A. Hall

Conflicts over health insurance coverage are inevitable. Initially, there are conflicts over what range of services to include in the benefits package. Then there will be conflicts over the application of the benefits package to specific individuals. Since both types of conflict are likely to involve people with serious medical problems, it is not surprising that they can become very intense.

Though the philosophic, religious, social, and moral issues that surround many of the debates over what to include in health insurance benefits can't be easily settled,1 it may be possible to develop a framework for resolving specific disputes over whether promised benefits will be covered in particular cases. This chapter begins with a brief overview of some of the broad issues that have influenced coverage determinations for both public and private insurers during the past several decades. We then focus on the litigation that has occurred when public and private insurers have interpreted coverage language to deny services to a specific individual, and we examine alternative methods to minimize the conflict between individuals and insurers. Drawing from our statistical analysis of reported court decisions, we evaluate various proposals for altering how courts resolve these disputes.


Defining benefits packages

Conflicts over insurance coverage usually begin when a public or private insurer seeks to design a benefits package. The design has three components: specifica-

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