June 21, 2002
Sean Caine, 410-576-6357
COURT DECISION UPHOLDS CONSUMERS' RIGHT TO EXTERNAL REVIEW OF HMO
Attorney General J. Joseph Curran, Jr. called yesterday's Supreme
Court decision that supports consumers' rights to external review
of HMOs' denials of health care, a win for Maryland consumers. The
decision in the Rush v. Moran case, which can be viewed at http://supct.law.cornell.edu/supct/,
upheld the external review mechanisms currently in place in 42 U.S.
is one of only 22 states that can actually provide assistance to
consumers who are appealing health insurance denials. The Health
Education and Advocacy Unit (HEAU) in the Attorney General's Consumer
Protection Division can assist consumers who are trying to get their
insurance carriers to provide coverage. If those efforts fail, HEAU
can help the consumer file a complaint with the Maryland Insurance
Administration (MIA). In cases where the care requested involves
a determination of medical necessity, MIA can have an independent
physician review the care denied. If the care is found to be medically
necessary, then MIA can order the insurance carrier to provide coverage
for the care.
decision will ensure that a larger number of people are not needlessly
denied coverage and or reimbursement for medically necessary procedures
from their health insurance providers," said Curran. "It
will enable the Office of the Attorney General and the Insurance
Administration to continue assisting consumers who wish to appeal
decisions made by their HMOs."
says the Unit has a 70 percent success rate in getting consumers'
health insurers to reverse their decision to deny coverage for treatment
when they are subject to MIA review. This is compared to a 56 percent
success rate when the insurance carrier is not subject to MIA. Health
consumers can contact the HEAU for assistance at 1-877-261-8807.