Suit Challenging Role of Regulators in Health Plan Disputes Rejected
A panel of the 3rd District Court of Appeals unanimously rejected a consumer lawsuit, ruling that the Department of Managed Health Care does not have to help patients challenge health plans when they are denied medical care or refused coverage for specific treatments, the Los Angeles Daily Journal reports.
The panel issued the ruling on Feb. 29 but agreed to publish portions of the opinion on Tuesday after DMHC officials said they were looking to set a precedent.
Plaintiffs in the lawsuit sought to require the department, which regulates HMOs, to heighten its role in patient-health plan disputes.
Lynne Randolph, a spokesperson for DMHC, said the plaintiffs mistook the duties of the agency and the law does not require the agency to "be the go-between."
Michael McClelland, senior counsel for DMHC, said he hoped the published opinion would inform consumers of their right to an independent medical review in cases where members disagree with health plans' coverage decisions.
Critics said the decision provides approval for state regulators to take a hands-off approach to consumer complaints, especially within the independent medical review system.
Jerry Flanagan of Consumer Watchdog said the panel's decision seems to define the department as a less involved consumer-rights group.
Harvey Frey, the attorney for the nine named plaintiffs, said state regulators have a bias towards the health insurance industry at all levels of the complaint process. Frey said the bias was evident in DMHC's unwillingness to provide patients with their medical records or to explain in writing why their requests are denied.
Frey said he will appeal the decision in the state Supreme Court (George, Los Angeles Daily Journal, 4/3).