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HMO Lawsuits Gathering Steam

While lawmakers vote on whether patients can sue health insurers, two lawsuits filed this week accuse HMOs of misleading members of misleading members about how they determine coverage fees and pay doctors.

A federal lawsuit was filed in Philadelphia Monday against Aetna Inc.'s US Healthcare division. The suit, seeking class-action status, was filed on behalf of Anthony Conte of Wilmington, Del., and all other members of Aetna US Healthcare's HMO plans who receive their coverage as an employee benefit.

Jerome Marcus, an attorney with the law firm that filed the suit, said Conte was put at a disadvantage when he enrolled in the plan by not getting information about how his doctor is paid. Doctors are penalized for prescribing medication and ordering treatment that falls outside Aetna's guidelines, Marcus said.

The lawsuit alleges that Hartford, Conn.-based Aetna also gives doctors financial incentives to influence their medical decisions. The suit seeks to force Aetna to make such disclosures and pay the costs of bringing the suit and compensatory damages.

Brochures and other health plan information packets do not describe such information to enrollees, which affects their ability to make informed decisions about the plan, their doctors' advice and the treatment that is prescribed, according to the lawsuit.

"This is part of a wave of similar actions by trial lawyers," Aetna spokesman Fred Laberge said Thursday. "They are targeting the health care industry for their own profits at the expense of small businesses and average American families who are struggling to afford quality health care."

Aetna insures 21 million people, almost 7 million of whom are in its HMO.

Another suit filed Monday in Miami accuses Humana Inc. of misleading its members by not telling them that cost -- not medical need -- is the main factor behind its decisions on what medical care it approves for members.

"Humana used undisclosed criteria that were unrelated to patients' medical needs," said Joseph Sellers, a partner in the law firm of Cohen, Milstein, Hausfeld & Toll.

"We believe that this is plain old fraud," he told CBS News Correspondent Dan Raviv.

Louisville, Ky.-based Humana paid cash bonuses to claim reviewers and had financial arrangements with doctors "that were clearly designed to reduce the number of patient claims that would be approved," the suit says.

Humana officials said they could not comment on the specific allegations because they did not have a copy of the suit. But the company said it planned a vigorous defense.

It also said it supports a process whereby independent physicians determine whether a requested health service is appropriate.

Humana, one of the nation's largest managed health care companies, has about 6.1 million members in 15 states and Puerto Rico.

The suit, seeking class-action status, was filed in federal district court in Miami on behalf of two Riviera Bach, Fla. police officers.