SUPREME COURT TO RULE ON PATIENTS' RIGHT TO SUE HMOS.

Byline: Staff and Wire Reports

WASHINGTON - The Supreme Court said Monday that it will clarify when patients can sue health insurers for denying treatment that a doctor recommends.

The court will use the case of a Texas woman whose HMO gave her only one day in the hospital to recover from a hysterectomy. The facts of Ruby Calad's case are the focal point of many patients' frustration with managed care health plans, which attempt to lower costs by limiting coverage and treatment options.

``That is the quintessential HMO horror story,'' said George Parker Young, Calad's lawyer. ``They gave her one day after major female surgery,'' even though her doctor objected. ``It kind of sums up (patients') worst fears about HMOs.''

The court also agreed to hear a companion case from Texas involving a post-polio patient required to use a cheaper pain pill than his doctor had recommended. Juan Davila claims he suffered bleeding ulcers and nearly had a heart attack.

Calad and Davila ended up in the emergency room, and both later sued over reportedly shoddy treatment.

Patients-rights advocates and trial lawyers say health maintenance organizations need the threat of lawsuits to ensure they don't shortchange patients. HMOs say lawsuits drive up costs for everyone and that they must draw the line somewhere.

Employer-sponsored health insurance covers nearly 160 million employees and their families, as well as 16 million retirees, according to court filings in a related lawsuit. As of 2001, 93 percent of employees with employer-sponsored health plans were enrolled in some kind of managed care.

Some in Congress have pushed for national patients-rights legislation that would allow patients to sue over reported injuries, and HMOs lobbied hard against it. The broadest recent effort faltered two years ago.

For California, ``the important question here is whether federal law pre- empts the state's law,'' said Russell Korobkin, professor of law at the University of California, Los Angeles.

Currently, patients can sue managed-care companies in California. But the Department of Managed Care has set up an independent review committee to help patients sort out their problems with health insurers before relying on litigation. The committee is made up of doctors with no economic incentive to rule in favor of a patient or an HMO, according to David Zingale, founding director of California's Department of Managed Care.

Zingale said if the federal government has more power in terms of patients' rights, it will be a setback for California. ``Right now, our patients' right are among the toughest in the nation,'' he said.

But what remains today is a web of unwieldy laws and lower court rulings governing where patients can bring their lawsuits and what they can ask for.

The cases before the Supreme Court involve appeals brought by two health insurers who lost a fight in a lower court over whether Calad and Davila could sue for medical malpractice or negligence. Lower courts nationwide have split over whether such suits against HMOs belong in state courts or federal courts.

Patients and their lawyers generally want to make their case in state courts, with the potential for high punitive and compensatory damage awards from juries. Insurers say claims like those brought by Calad and Davila belong in federal court, where the most the patient could recover is the value of the benefit denied by the HMO.

The insurance industry wants the Supreme Court to sort out the confusion, said Susan Pisano, a spokeswoman for the American Association of Health Plans.

``Employers really need, in an era of rising costs and an increasing number of uninsured (patients), to be able to use the tools available to them to promote quality and affordability,'' Pisano said.