HMO Reform: A Much Needed Process Has Begun
By Jim Szaller
I am a youthful, gregarious and athletic 50 year old male, happily married and blessed with a wonderful eight year old daughter. I've worked hard, and life and the Lord have been good to me and mine. I have had only a few sick days, and have always considered myself extremely healthy. So imagine my surprise, and fear, when a month ago I was rushed by ambulance to the nearest hospital ER with severe debilitating chest pains!
Thankfully I am A-1 healthy today. I again feel youthful, gregarious and athletic. But the trip to the hospital, and the subsequent treatment, continues to concern me. Not because my health isn't great, but because I am concerned and disheartened by the way the insurance company "took care of me," and fearful about my future coverage and that of my family and friends. As a matter of fact, I am fearful for everyone whose health insurance is through an employer initiated HMO.
HMOs are insurance companies, and most Americans are insured through HMOs. But, I found that HMOs have very little incentive to honor their contract of insurance and to pay for all needed hospital and medical bills. If HMO insurance is paid, at least partially, by an employer, federal law (ERISA -- Employee Retirement Income Security Act of 1974) usually prohibits a personal injury lawsuit against the HMO for injury or death caused by the HMO's denial of medical benefits. For example, if my HMO denied me the "benefit" of hospitalization for my heart condition, and if I had died, my family could not bring a lawsuit against the HMO for my death. The federal law limits recovery to the cost of the denied benefit -- for example, $500 for the night in the hospital that had been denied.
Since the most HMOs can be liable for in a subsequent lawsuit is the cost of the benefit they denied (and not for injury or death), what incentive do they have to pay for a benefit in the first instance? The answer is simple. They have no incentive. In my time of medical need, after I had jumped through the necessary hoops with my HMO, and the minor surgery had finally been performed, I decided I would join the fight to change the law. I had to jump through too many hoops to get the benefits due me, and had to fight too hard to obtain the insurance coverage I paid for. Presently pending in the United States Senate are a number of health care reform bills. Only one bill, a compromise bill between Democrats and Republicans, gives patients the right to sue HMOs. Hopefully it will pass, even though it does not provide as much protection to patients as the bill narrowly defeated in July, co-sponsored by Congressman Kucinich.
Congressman Kucinich met with me and other lawyers to discuss how best to change ERISA. If an adequate bill protecting patients is not passed this year, he has promised to again support a Patient Bill of Rights next year. He, and the lawyers that met with him at Brown & Szaller to discuss the HMO statutory immunity (at the expense of patients' rights), are committed to the passage of legislation to protect victims of HMO abuse.
If you or a family member has been denied coverage by an HMO, and serious injury or death resulted, please contact me immediately, for two reasons: first, I will make certain that Congress is informed how our clients have been abused by HMOs, and also decide whether I can or cannot help you legally (there are situations in which I can help); second, if your HMO coverage is not paid by your employer (or, in some cases, if you're a government employee), we can help you obtain compensation for your subsequent injury.