Editorial: Patients get another hit

Tuesday, June 22, 2004 | 9:22 a.m.

In recent years states have passed laws allowing patients to sue health insurance companies if they've been denied medical care. But on Monday the Supreme Court ruled unanimously that federal law allows these kinds of suits against HMOS to only be filed in federal court. The net effect of the Supreme Court's decision will mean that HMOs won't be held accountable -- even in the most blatant decisions where they irresponsibly deny medical care. The reason is that the federal law governing such suits essentially says that patients can only recover the dollar value of the benefit that's been denied them instead of more costly malpractice damages, which can take in factors such as lost wages and medical bills.

The federal law in question -- the Employee Retirement Income Security Act -- was passed in 1974 to encourage employers to set up employee benefit plans by ensuring that there would be uniformity in governing them, not a mixture of regulations done differently by all 50 states. HMOs, since 1974, have become much more than insurers, however. They actually have started making medical decisions that once used to be the sole province of doctors. Insurers, then, should be held accountable for medical malpractice.

The need for accountability is evidenced by the case the Supreme Court considered, a case consolidated from two separate lawsuits. In the first lawsuit, an HMO denied a brand-name prescription drug for a patient suffering from arthritis pain and would only authorize a cheaper substitute. A short time later the patient said he developed a bleeding ulcer, which he said was due to the side effects of the less-expensive drug. In the second lawsuit, a doctor authorized a patient to spend several days in a hospital following a hysterectomy in order to recover. The health insurer would pay for just one day, however. The patient said this short stay later resulted in her developing serious complications, which caused her to be hospitalized again.

The bottom line, in the wake of the Supreme Court's decision, is that it's now up to Congress to change federal law so that patients can sue in state courts if they've been harmed. The politically powerful insurance companies have been able to use their influence with Republican leaders in Congress, however, to bottle up patients' rights legislation that Democrats have pushed for years. Unfortunately, we don't see that changing anytime soon -- at least as long as Republicans control Congress.