Consumer crusade builds against health care rationing by insurers.

What happens when your medical plan refuses to give you the care you believe you need? There's an appeals procedure. But it isn't much good if you're in mortal danger or serious pain, or you're being thrown out of the hospital just a few hours after major surgery.

Welcome to the new world of medical rationing. It's going to get worse, as health costs rise and employers fight to hold their health care expenses down. But patients have ways of fighting back. In their anger and fear, they're creating a new political movement: a consumer crusade for patients' rights.

Tens of thousands of patients and their relatives have called, written, faxed and e-mailed their legislators, protesting against what they see as heartless medical care. Almost every state has recently passed at least one law reversing the new cutbacks in treatment.

The managed care companies argue that government has no business interfering with the sacred insurer-patient relationship. (The relationship used to be doctor-patient. If it were still, this column wouldn't be written.)

HMOs have a point when they say that the legislatures shouldn't be micromanaging medical care.

Nevertheless, laws get passed when managed care plans go too far.

Here are some of the seething consumer questions that the states have addressed so far, according to the Health Policy Tracking Service of the National Conference of State Legislatures in Washington, D.C.:

* Which doctor should you call? Normally, you have to start with a primary care physician. To see a specialist under the plan, you need his or her permission. Gynecologists are specialists. But a majority of women consider them their primary doctors, according to a 1993 Gallup Poll.

Accordingly, the law in 20 states (including California) now allows women in managed care plans to see gynecologists and obstetricians without getting another doctor's permission first.

* When are emergencies paid for? HMOs normally don't cover unauthorized treatment in nonmember hospitals.

They'll pay if there's an emergency. But with perfect hindsight, they may decide there was no emergency. That pain in your chest turned out to be indigestion, not a heart attack. You have to pay the emergency room bill.

In 17 states (including California), HMOs now have to pay for emergency treatment at non-member hospitals, if a prudent person might think that a real danger existed.

* Who can you trust? Some managed care plans order doctors not to tell patients about alternative treatments (some of them costly) or whether the doctor has a financial incentive not to treat. They also aren't supposed to discuss competing plans.

Gag rules like these are now illegal in 20 states, including California. Health plans aren't supposed to retaliate against doctors who talk. But a plan can come up with many reasons for firing a doctor, so it's hard to know how well anti-gag laws really work.

* Will you be offered a last chance at life? Only a handful of states require managed care plans to allow bone marrow transplants for women with advanced breast cancer. Many plans pay voluntarily, but you can't count on it.

* Can you stay in the hospital after a mastectomy? "That's this year's big issue," says Molly Stauffer, policy specialist at the Health Policy Tracking Service.

Mastectomies aren't hopscotch. But some HMOs don't let patients stay in the hospital overnight. They go home and rely on relatives to tend the wound.

Thanks to female fury, 15 states (including California) have introduced bills requiring inpatient stays for mastectomy patients. New Jersey may become the first state to get such a bill through the legislature.

Even the American Association of Health Plans, the trade association for managed care, has come out in favor of letting women stay in the hospital if they want to.

You'll notice that only politically powerful groups are getting rationing reversed. That's no way to run a medical system. But neither is it smart to put public health in the hands of insurers who only want to get their profits and bonuses up.

Insurance scam

It's the job of each state to regulate the insurance industry so that consumers won't get ripped off. If you need further proof that most states are not doing their job, take a look at the legal thievery allowed in credit life insurance. Often, your elected so-called "representatives" are to blame.

Credit life pays off a particular loan if you die with payments still due. It's typically packaged with disability insurance, and sold in conjunction with installment loans, auto loans, personal loans and credit cards.

An estimated 60 million consumer loans are currently covered, according to the Consumer Credit Insurance Association in Chicago.

Credit life coverage can be a useful. It's a simple way of leaving your family without consumer debt. it also covers people with certain health problems who might not find insurance somewhere else.

The shame of credit life is its cost. In most states, the lenders who sell this insurance brazenly mark up its price. They've got a monopoly on the sale. If you get a loan from XYZ bank or auto dealer, there's only one policy you can buy. Lenders tend to choose the policies that pay them the highest sales commissions rather than those that cost the customer the least. Just as shamefully, most states do nothing about this. Many state legislatures even protect the scam.

The federal government knows that something is rotten here. Bank auditors for the Office of the Comptroller of the Currency now ask banks roughly the following question: "Did you pick this insurance policy for its consumer benefits or for the high commissions you earn?"

But just asking that question will not help, as long as most states protect the insurers, the banks, the auto dealers and the small finance companies instead of you. They make a mint from credit life and their owned-and-operated legislators make sure it stays that way.

Syndicated columnist Jane Bryant Quinn can be reached in care of the Washington Post Writers Group, 1150 15th St., Washington D.C. 20071-9200.