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Washington patients can now sue their HMOs for damages

Under Washington State's Patient's Bill of Rights law, HMOs can be held legally liable and sued for damages for their treatment decisions if a customer suffers significant impairment or disfigurement, or severe or chronic pain as a result. "This gives consumers a much larger weapon to make their insurance carriers behave responsibly," says Jim Stevenson, a spokesman for the Washington Department of Insurance.

Nationally, there is little recourse against an HMO. The federal Employee Retirement Income Security Act (ERISA) allows consumers to sue health plans that deny coverage of treatment, but only to have that medical care covered or to recoup the cost of the treatment itself, not for damages. "Most people don't have the luxury of going to court for three years to get treatment," Stevenson notes.

This gives consumers a much larger weapon to make their insurance carriers behave responsibly."

But the Health Insurance Association of America (HIAA), an industry trade group that routinely frowns on patient rights bills, says it's too early to tell if such laws will spawn rampant litigation against HMOs. "They raised the same argument in Texas," notes spokesperson Richard Coorsh. "There's one suit to be resolved in Texas, and that outcome will determine whether additional suits will follow. It's just too early to make this kind of prediction."

On the other hand, he says, there's no question that costs will rise in the wake of such legislation, which, in turn, will cause an increase in premiums and make health insurance more unaffordable. "There are 44 million Americans out there for whom this discussion is not even an academic debate," Coorsh says, referring to the number of uninsured. "Ask them if they're going to feel better about being able to sue."

Washington's health care availability was in poor condition for several years, the effect of rising health care premiums caused by the high amount of state mandated benefits, limited repayment to medical care providers from government programs and rising medical liability insurance costs for physicians and hospitals. While the situation is not fully repaired, most state residents can find available and affordable health care in their areas.

Other Washington state Patient's Bill of Rights provisions

  • Grievances. Customers must receive written notification of their HMO's decision to deny, modify, reduce, or stop payment or coverage of certain health services. In addition, health plans must assist customers in appealing those decisions and provide information on their rights to a second opinion.
  • Independent reviews. Customers who have exhausted the internal grievance process at their HMOs may have the option of having their cases heard by an independent panel of medical experts. The panel can also step in when the health plan does not respond to a grievance on time or to review decisions about the interpretation of the health plan contract.
  • Privacy. HMOs must adopt policies to protect each customer's rights to privacy and confidentiality granted under state and federal laws — such as the new HIPPA regulations which took effect in mid-April, 2003.
  • Benefits. All HMO customers must be given a list of covered benefits, exclusions, limitations, costs, and procedural information. HMOs cannot forbid doctors from talking to patients about their care, whether that care is covered by the HMO or not, nor can HMOs preclude doctors from advocating on behalf of their patients.
  • Referrals. HMO customers are given direct access to chiropractors, bypassing the referral process. In addition, customers with serious or complicated illnesses must be granted a standing referral to a specialist

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