WASHINGTON — WASHINGTON -- Patients whose health maintenance organizations deny them a medical treatment or drug benefit have a right to a second opinion from outside doctors, the Supreme Court ruled Thursday, upholding the new "independent review" laws in California and 41 other states.
The 5-4 decision endorses a middle-ground reform in the continuing fight between consumer advocates and the health insurance industry about who should make medical decisions.
For many patients, the independent review system promises a quick and reliable answer to the question of whether a medical treatment is wise and necessary.
If they appeal to a state board, then a medical specialist or a panel of three doctors will review their case. If they agree that the treatment or drug is needed, the board can force the HMO to pay for it.
But many patients are unaware of the review system, and relatively few have taken advantage of it.
California's review system was launched in January 2001, and the Department of Managed Health Care in Sacramento said it had handled the claims of more than 800 people.
In roughly two-thirds of those cases, the outside doctors supported the HMOs' original decisions. In the remainder of cases, the doctors sided with patients and persuaded the HMOs to provide the benefit or ordered that it be paid.
Daniel Zingale, the director of the state agency, said the system operates on the premise that "patients want to see a doctor, not a lawyer. They want the care before the damage is done, rather than suing after the fact."
In Thursday's ruling, the high court retreated somewhat from earlier rulings that had shielded HMOs from virtually all state laws.
In 1987, the court ruled that the federal law regulating employee benefits did not allow states to require employers to add more benefits. If employees could sue in state court over a medical benefit, that would violate the federal rule by forcing employers to pay more, the court said.
This ruling loomed large in the 1990s, when most employers decided to insure their workers through managed care plans, which were designed to hold down costs for employers. Sometimes, the plans would not pay for treatments, including those for sick children.
Outraged, patients learned that they could not sue their HMOs because the insurers were shielded by the federal law.
As public anger grew, state and federal lawmakers looked for a better way of protecting patients.
