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Supreme Court limits HMO lawsuits.
1Navigant Consulting, Chicago, Illinois, USA. afine@navigantconsulting.com
Managed Care Quarterly
|February 11, 2005
Summary
The Employee Retirement Income Security Act (ERISA) permits patients to claim the value of denied medical services. However, it does not allow compensation for injuries caused by the lack of care.
Area of Science:
- Health Law
- Patient Rights
- Medical Benefits
Background:
- The Employee Retirement Income Security Act (ERISA) governs employee benefit plans, including health insurance.
- Patients denied necessary medical care face challenges in seeking compensation for harm.
- Legal recourse for beneficiaries of ERISA plans is often limited.
Purpose of the Study:
- To clarify the extent of recovery available to patients under ERISA for denied medical benefits.
- To analyze the limitations of ERISA in compensating for consequential damages due to lack of care.
Main Methods:
- Review of ERISA case law and statutory provisions.
- Analysis of judicial interpretations regarding benefit recovery versus damages.
Main Results:
- ERISA allows recovery of the value of the denied test, drug, or treatment.
- ERISA explicitly excludes recovery for damages resulting from injuries due to lack of care.
Conclusions:
- ERISA provides a specific avenue for recouping the cost of denied medical services.
- Patients seeking compensation for harm resulting from denied care may need to explore legal avenues beyond ERISA.