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When courts review medical appropriateness
G Anderson1, M A Hall, T R Smith
1Department of Health Policy and Management, Medicine, and International Health, Johns Hopkins University, Baltimore, MD, USA.
Medical Care
|August 26, 1998
Summary
Courts ordered insurers to cover medical treatments in 57% of cases reviewed. Contract language and patient condition significantly influenced coverage decisions, not the assessment process itself.
Area of Science:
- Health Law
- Insurance Law
- Medical Appropriateness
Background:
- Insurers increasingly use medical appropriateness criteria for coverage decisions.
- Litigation arises when patients dispute these criteria.
Purpose of the Study:
- To analyze court responses to insurer use of medical appropriateness criteria.
- To identify factors influencing court decisions on health insurance coverage.
Main Methods:
- Structured review of federal and state court decisions (1960-1994).
- Analysis of 124 relevant cases explicitly mentioning medical appropriateness criteria.
- Outcome variable: court order for insurer to provide coverage.
Main Results:
- In 57% of 185 definitive decisions, insurers were ordered to pay.
- Assessment process details (formal/informal, assessor) did not impact court rulings.
- Key predictors for coverage included court jurisdiction, contract terms, patient condition severity, and treatment efficacy.
Conclusions:
- Focusing on insurance contract wording is crucial for judicial acceptance of medical appropriateness criteria.
- Clear contract language may be more influential than the specifics of medical assessments.