Court To Hear Texans' HMO Suits

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Just a day after undergoing a hysterectomy, Ruby Calad had to leave a Houston hospital because her insurance company would not pay for a longer stay.

A few days later, she was rushed to the emergency room with complications she says could have been avoided had she remained hospitalized.

Nearly five years later, she says she remains in constant pain and needs more surgery. She says the ordeal caused the breakup of her marriage.

Calad blames her insurer, Cigna Heathcare of Texas, and the case stemming from her lawsuit against the company will be argued Tuesday before the U.S. Supreme Court.

Her case — and a companion case that the high court will also hear — could establish what rights patients have to sue when an HMO refuses to pay for recommended care. Specifically, the Supreme Court is being asked to decide whether such cases can be heard in state court or federal court.

In state courts, juries can award high amounts for punitive damages. In federal court, a patient can receive nothing more than the value of the benefit denied by the health maintenance organization.

"I feel like my little voice is going to be heard across the United States," said Calad, 49, who lives in Sugar Land. "It really upsets me for other people who are going through this. I just want somebody to make changes in HMOs."

The other case involves Juan Davila of Ponder, about 30 miles north of Fort Worth. Davila sued Aetna Health after it refused to pay for a more expensive pain pill recommended by his doctor. The cheaper medication caused bleeding ulcers for the post-polio patient, and he almost had a heart attack, Davila said.

Both cases were filed in state court in 2000 under a 1997 Texas law allowing patients to sue HMOs. But the cases were transferred to federal court after the insurers said Calad and Davila should have contested the refusal of their claims under a 1974 federal law called the Employee Retirement Income Security Act. And ERISA does not allow patient lawsuits for monetary damages.

A federal appeals court in 2002 ruled that Calad and Davila could indeed sue for malpractice damages in state court. But the HMOs appealed to the Supreme Court.

David Carter, an Aetna spokesman, said that ERISA has its own procedures for reviewing or appealing coverage decisions, and that sidestepping the federal law would lead to more lawsuits, which would drive up health care costs.

ERISA has helped companies provide affordable quality health care coverage for their employees, he said.

"It provides employees a prompt, responsive way to address disputes while still receiving care. The court system is a poor and costly substitute," Carter said.

But the attorney for Calad and Davila, George Parker Young, said states should have the right to regulate decisions by HMOs.

"The incentive in managed care is that every dollar saved is a dollar to their bottom line," Young said. "If there's a lack of accountability, then the incentive is to skimp on care inappropriately."

Nearly 160 million employees and their families, as well as 16 million retirees, are covered by employer-sponsored health insurance, according to court filings in a related lawsuit. As of 2001, 93 percent of employees with such health plans were enrolled in some type of managed care.
  • Lloyd Vries

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