Author Affiliations: Hirsch Health Law and Policy Program, The George Washington University School of Public Health and Health Sciences, Washington, DC.
The article by Studdert and Gresenz1 in
this issue of THE JOURNAL is a valuable contribution to the debate about US
managed care policy and patients' rights. The analysis of enrollee appeals
from 2 California-based health maintenance organizations (HMOs) provides an
important look inside the "black box" of prospective coverage decision making,
which typically remains hidden from view in the absence of judicial appeal
or the very occasional government study. Judicial review of prospective coverage
decisions is rare because of the cost and complexity of litigation. Even retrospective
appeals are unusual, given the inability in most health insurance disputes
to recover damages for death or injuries caused by wrongful denial of benefits
by group health plans,2 a limitation that reduces
the economic feasibility of litigation.
Rosenbaum S. Managed Care and Patients' Rights. JAMA. 2003;289(7):906-907. doi:10.1001/jama.289.7.906