Clarification of Answer by
29 Jul 2003 01:38 PDT
Are you aware that a class action lawsuit was filed against Humana
Inc. in October 1999:
".... Lawyers, speaking at a news conference at the Washington-based
law firm of Cohen, Milstein, Hausfeld & Toll, said the lawsuit was the
first of its kind against a health maintenance organization and would
seek "a substantial amount" of compensation.
.... Humana, covered up from its subscribers the true way it decided
whether to approve treatment and whether to pay claims of its
subscribers," said Stephen Neuwirth of Boies & Schiller, which is
representing some of the plaintiffs"
... Humana provides direct financial incentives to treating physicians
... to deny coverage to individuals ... even where the proposed
treatment satisfies the Humana medical necessity definition
... The suit also alleged that claim reviewers often had no medical
"Humana thus failed to inform (subscribers) that decisions respecting
medical necessity would be made by persons without the appropriate
medical experience or training to recognize medical necessity," "
A longer analysis of the topic:
And more about the whole issue of medical necessity and denial of
treatment, with a focus on individual cases, mainly involving Humana.
Some people have managed to get redress:
"Given these profit-driven practices of sacrificing human health on
the altar of corporate greed, it is little wonder that juries are
reacting with outrage and awarding mega-verdicts to managed cares
In January 1999, a California jury awarded $120.5 million to the widow
of a man who died of stomach cancer after Aetna U.S. Healthcare denied
treatment his doctor had requested.
A year later, in the Caitlyn Chipps case, a Florida jury awarded the
family $79.6 million. It's not about just one family, one juror
remarked afterward. It's a case about Humana's conduct toward many
people they insure. We wanted to send a message. "
And something closer to home geographically:
AMA, TMA criticize Texas' legal settlement with Aetna
The agreement has weak medical necessity provisions and could strip
patient appeal rights, the groups say.
By Sarah A. Klein, AMNews staff. June 19, 2000.
Medical Association web site)
Three state medical societies join HMO racketeering lawsuit
Texas, California and Georgia medical associations band together
against managed care. Court, they say, is their last resort to solve
prompt-payment and medical necessity concerns.
By Tanya Albert, AMNews staff. April 16, 2001.
"The Texas Legislature passed some of the strongest patient protection
laws in the nation, but insurance companies point to the federal
Employee Retirement Income Security Act of 1974 to protect them from
state laws, said TMA President Jim Rohack, MD.
... Among claims the medical associations make in the lawsuit are that
Do not use "medical necessity" criteria to make coverage and treatment
decisions or in reimbursing physicians. Instead, they say, HMOs use
cost-based criteria to approve or deny claims. "These undisclosed
cost-based criteria include defendants' own guidelines and criteria,
as well as guidelines developed in concert with third parties,
including but not limited to Milliman & Robertson and InterQual,"
... Aetna Inc. and its Prudential unit, Cigna Corp., United Health
Group, Humana Inc., Foundation Health Systems, PacifiCare Health
Systems, Coventry Health Care Inc. and WellPoint Health Networks are
named in the lawsuit."
Perhaps it might be worth contacting these people:
"The Bazelon Center for Mental Health Law is the leading national
legal advocate for people with mental illnesses or mental retardation.
Through precedent-setting litigation and in the public policy arena,
the Bazelon Center works to advance and preserve the rights of people
with mental illnesses and developmental disabilities."