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Sara Rosenbaum, JD

JAMA. 2003;289:906-907.

	Since this article does not have an abstract, we have provided the first 150 words of the full text and any section headings.

The article by Studdert and Gresenz¹ in this issue of THE JOURNAL is a valuable contribution to the debate about US managed care policy and patients' rights. The analysis of enrollee appeals from 2 California-based health maintenance organizations (HMOs) provides an important look inside the "black box" of prospective coverage decision making, which typically remains hidden from view in the absence of judicial appeal or the very occasional government study. Judicial review of prospective coverage decisions is rare because of the cost and complexity of litigation. Even retrospective appeals are unusual, given the inability in most health insurance disputes to recover damages for death or injuries caused by wrongful denial of benefits by group health plans,² a limitation that reduces the economic feasibility of litigation.

Based on direct review of thousands of appeals, the authors made several notable findings. First, appeals are rare. Four million enrollees produced . . . [Full Text of this Article]

Author Affiliations: Hirsch Health Law and Policy Program, The George Washington University School of Public Health and Health Sciences, Washington, DC.

RELATED ARTICLE

Enrollee Appeals of Preservice Coverage Denials at 2 Health Maintenance Organizations
David M. Studdert and Carole Roan Gresenz
JAMA. 2003;289(7):864-870.
ABSTRACT | FULL TEXT