In an Emergency
Be Ready To Fight!


From the publishers of the New England Journal of Medicine


     When a health plan blocks essential treatment by refusing to authorize it, there's no time to wait around for an internal appeal to be resolved. In life-or-death situations, consumers have two courses of action.
       State regulatory agencies can intervene immediately in those cases. Pamela Gaume of the California Department of Insurance recalls that her department, which regulates fee-for-service health plans, got involved immediately to force an insurance carrier to authorize a critical part of a bone-marrow transplant procedure.
       The insurer had tried to drop the patient's coverage in a "bureaucratic dispute over whether the extension of benefits for total disability ran concurrently with the coverage period mandated by COBRA (the federal Consolidated Omnibus Budget Reconciliation Act)," Gaume explains, demonstrating the bloodless technicalities that put lives at stake.
       The regulators that govern managed care will intervene similarly.
       The consumer's second option is to find an attorney to get a court to order treatment. Washington, D.C., lawyer Jacqueline Fox has used this recourse for clients a number of times. "It doesn't automatically mean the insurance company has to pay for the claim," she explains, "but they can't block you from getting a procedure." It's not difficult to persuade judges to issue court orders, she adds. "When all hell is breaking loose and we get the doctor to say this patient is going to die without the treatment, most judges don't want that blood on their hands."


. Grannan

HMOs Return
HMOs Return