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Supreme court to patients: No suits against HMOs in state courts
Physician Practice Advisor, June 22, 2004
Patients cannot sue HMOs in state court to recoup damages caused by administrative decisions, according to a unanimous Supreme Court decision on June 21.
The decision is the result of suits filed by two Texas residents who said that the administrative rules for their HMOs, Aetna and Cigna Healthcare, caused physicians to alter their treatment plans in ways that caused them injury. One case involved a patient who developed bleeding ulcers because of two medications he had to take before his insurer would pay for the more expensive medication the doctor originally prescribed. The second case involved a patient who was readmitted to the hospital for complications. The woman's doctor wanted her to stay an extra day, but her insurer would not cover the additional cost.
In the opinion issued by the court, Justice Clarence Thomas explained that declining to pay for coverage is not the same as denying procedures because patients still have the option to get the care and then seek reimbursement for the cost of the uncovered procedures in federal court. This decision does not alter HMO patients' rights to sue their physicians. Opinions by Justices Ruth Bader Ginsburg and Stephne Breyer acknowledged a "regulatory vaccum" in a patients' right to file suit against HMOs.
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