1. Kennedy, Maureen Shawn MA, RN

Article Content

Patients may no longer be able to sue managed care organizations after receiving inadequate care because of a recent U.S. Supreme Court ruling. The court struck down the Texas Health Care Liability Act (and effectively pulled the teeth out of similar laws in 10 other states), which held managed care organizations liable for failing to provide coverage physicians deemed to be medically necessary. The two HMOs being sued argued that the state had no legal authority to allow such suits because such cases fall under the purview of the federal Employee Retirement Income Security Act (ERISA) of 1974. On June 21 the Supreme Court ruled unanimously that ERISA's provisions preempt state laws.


Proponents of the ruling-primarily managed care organizations-claim that better care will result because costs will decline if the companies don't have to shell out enormous sums to litigants. Opponents counter that care will suffer because insurers will once again have no incentive to provide necessary treatment and that they will continue to, as some say, practice medicine without licenses, gainsaying physicians, refusing to allow testing for illness, denying coverage of treatment, and leaving decisions to review boards (and thus outlasting patients' pocketbooks, ability to fight, or lives).


In a concurring opinion, Justices Ginsberg and Breyer noted that while ERISA does preempt virtually all "state law remedies," it provides little refuge in federal courts and that either Congress or the courts must act quickly to fix a situation they call untenable.-Doug Brandt

FIGURE. Ruby Calad, ... - Click to enlarge in new windowFIGURE. Ruby Calad, one of the plantiffs whose suit against an HMO went to the Supreme Court. Calad was discharged early after a hysterectomy because her insurer refused to pay for additional days; she subsequently went to the ED with complications.