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Lawsuit accuses PruCare of poor care

Another lawsuit filed against a major health insurer, this time Prudential HealthCare, contends that HMO officials denied coverage for patients' treatment even though they were not qualified to do so and that they based their decisions on criteria that didn't meet medical standards.

Potential class members

Potential members of the national class action lawsuit filed against Prudential HealthCare include all customers of PruCare in the United States who were or are participants or beneficiaries in employee welfare benefit plans through which health insurance coverage was or is provided by HMO or point-of-service plans administered by PruCare. PruCare has about 6.6 million customers nationwide.

The lawsuit accuses PruCare of such practices as limiting new mothers to a 24-hour hospital stay, discharging stroke patients in two days, recommending that mastectomies be performed on an outpatient basis, and limiting treatment of Lyme disease to 28 days, even for chronic cases. "Each of these guidelines . . . are inconsistent with the prevailing recommendations in the medical community," the lawsuit charges.

The lawsuit, which is seeking federal class action status, was filed April 11 in U.S. District Court in New Jersey by the law firms Pomerantz Haudek Block Grossman & Gross and Milberg Weiss Bershad Hynes & and Lerach.

PruCare was purchased by Aetna U.S. Healthcare for $1 billion in August 1999, making Aetna the nation's leading provider of health insurance benefits, with more than 21 million customers.

The plaintiffs' attorneys say that PruCare breached the terms of its health care plans by using procedures for determining the medical necessity of patient care that are inconsistent or conflict with the prevailing opinion in the medical community, leading to improper denial of treatment.

The lawsuit also contends that the HMO's decision-makers, which allegedly include untrained claims administrators and unqualified doctors, do not take into account the individual patient's circumstances when determining whether the person needs medical care. Rather, it says, PruCare adheres to substandard actuarial guidelines in an effort to reduce medical expenses. The lawsuit cites PruCare's guidelines for a 24-hour hospital maternity stay after giving birth, instead of 48 hours. It also contends that while the American Medical Association recommends a week-long hospital stay for certain stroke patients, PruCare covered only a two-day stay.

Keep it a secret

In addition, the lawsuit says that the doctors who contract with PruCare risk being terminated if they discuss treatment options with their patients that aren't covered by the HMO. "Without such information," the lawsuit says, "a patient's right to informed consent concerning the medical care offered by PruCare has been violated."

The lawsuit seeks to force PruCare to comply with the contractual obligations spelled out in its health plans.

Aetna officials have little to say about the lawsuit but insist it has no merit. "We are currently reviewing the suit," says company spokesperson David Carter. "However, it appears to be another attempt by the plaintiffs' bar to utilize the courts to make fundamental changes in the way that managed care plans are governed."

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