Maryland supports appeals of health plan decisions

Physicians applaud a court ruling that the state insurance commissioner can impose fines and order plans to pay for improperly denied treatments.

By Tanya Albert, AMNews staff. Dec. 2, 2002.

External appeal laws that many say strengthen the physician-patient relationship got another boost from the courts.

The highest court in Maryland has upheld a law that gives health plan subscribers the right to independent, external reviews when HMOs deny treatments that their doctors say are medically necessary.

The Maryland Court of Appeals in November ruled that the Employee Retirement Income Security Act of 1974 does not preempt the 1998 Maryland statute.

The law gives the Maryland insurance commissioner -- after he or an independent medical expert reviews the facts -- the right to order a health plan to pay for medically necessary services it originally denied, as well as the right to fine a plan for denying the treatment.

"We regard it as a huge win," said T. Michael Preston, executive director of the Maryland State Medical Society, which pushed for the initial legislation. "It is a useful process for physicians and patients. It requires a physician and patient to fight together for what they believe they need and what they feel is right."

The Maryland decision comes on the heels of a U.S. Supreme Court ruling that ERISA, a federal law that health plans have successfully used to defend themselves for years, did not preempt an Illinois law that required health plans to abide by external reviewers' decisions.

The court said external review in Illinois was an insurance regulation and that insurance oversight has traditionally rested with the states. [...]