Supreme Court Ruling on HMOs Irks Physicians

By Frieden, Joyce | Clinical Psychiatry News, September 2004 | Go to article overview

Supreme Court Ruling on HMOs Irks Physicians


Frieden, Joyce, Clinical Psychiatry News


The Supreme Court's recent ruling that patients cannot sue their health maintenance organizations will be detrimental to patients, according to leaders from several physician organizations.

"It is a bad thing for patients," said Dr. Michael Fleming, president of the American Academy of Family Physicians. "Frankly, HMOs need to be held responsible, just as I'm held responsible as a physician if I make a decision."

The Supreme Court case, known as Aetna Health Inc. v. Davila, involved two Texas patients who claimed they were wrong-fully denied benefits by their respective health plans. One patient, Ruby Calad, sued Cigna Healthcare of Texas after she underwent a hysterectomy and the plan's discharge nurse said Ms. Calad did not meet the criteria for an extended hospital stay, even though her physician had recommended it. Ms. Calad was discharged but suffered complications and was readmitted to the hospital. Her suit alleges that these complications would not have occurred had Cigna approved coverage for the longer stay.

The second case involved Juan Davila, whose physician recommended rofecoxib (Vioxx, Merck & Co. Inc.) to treat Mr. Davila's arthritis.

Aetna, Mr. Davila's health plan, refused to pay for Vioxx. Mr. Davila began taking naproxen (Naprosyn, Roche Pharmaceuticals) but allegedly suffered a severe reaction that required extensive treatment and hospitalization.

In their suits, Ms. Calad and Mr. Davila contended that a 1997 Texas law known as the Texas Health Care Liability Act prohibited the plans from improperly denying needed medical care.

But the health plans countered that the Texas law was preempted by the federal Employee Retirement Income Security Act (ERISA), which governs multistate health plans.

Unlike the Texas law, which allows patients to collect monetary damages for injuries caused by denied coverage, ERISA limits damages to the actual care that was improperly denied. …

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