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California patients allege that the state's managed care officials fail to protect them

California consumer advocacy group and nine HMO patients from around the state are suing the California Department of Managed Health Care (DMHC) and its officers for allegedly not doing their jobs.

"Without timely access to these documents, a patient has no way to identify and correct misleading or false statements."

The California Consumer Health Care Council (CCHC) filed the lawsuit against the DMHC in Sacramento Superior Court on Sept. 11, 2001. It alleges that the DMHC and its officers fail to enforce consumer protection laws by disregarding "misrepresentations and false statements" made by HMOs in violation of the Knox-Keene Act, the 1975 law that regulates California HMOs. The nine HMO patients, members of various California health insurance plans, have filed complaints against their plans with both the DMHC and the CCHC.

The patients are not seeking financial compensation for any harm incurred. Instead, they are asking the court to order the DMHC to provide copies of materials submitted to the department by HMOs responding to patient's complaints — or require the HMOs to provide the documentation directly to the patients.

"There is no case of a patient rights law being violated where DMHC has failed to enforce the law."

"Without timely access to these documents, a patient has no way to identify and correct misleading or false statements," says John Metz, CCHC chairman. "Unless these false statements are corrected, the decisions that DMHC makes will be wrong and it is our experience that the decisions almost always favor the HMO."

DMHC Director Daniel Zingale, who is named in the lawsuit, says his department has served more than 100,000 consumers since its inception in July 2000. "I am not aware of any of them raising the issues brought by Mr. Metz on behalf of these nine," Zingale says. "We do take these issues raised by these, and any, consumers seriously. Their records show their cases were thoroughly investigated. I am aware of no evidence that any written request for information by these consumers was ever denied by DMHC. Most importantly, there is no case of a patient rights law being violated where DMHC has failed to enforce the law."

Core argument

At the center of the complaint is a request for the court to issue a "writ of mandate" to compel the DMHC to do its job as the agency that oversees California's HMOs. It alleges that the DMHC "flouts the rule of law and deprives complaintants of the ability to obtain needed medical benefits, subjecting them to pain, ill health, and shortened life expectancy, as well as significant financial loss" by:

  • Accepting false, misleading, and/or materially incomplete statements from HMOs as a basis for its determinations in complaints filed by health insurance consumers.
  • Failing to provide consumers with copies of the materials supplied by each plan, upon which DMHC relies in making its decisions.
  • Failing to give full, reasoned explanations for their refusal to help consumers.
  • Refusing to "fully and faithfully" execute the laws enacted to protect consumers.

According to Dr. Harvey Frey, attorney for the consumers and director of the Health Administration Responsibility Project in California, a writ of mandate is an injunction used by the courts "to say this is your duty — go do it."

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