Supreme Court Awards Decision to SLP Landmark Patients’ Rights Case Is Finally Ended On the Pulse
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On the Pulse  |   July 01, 2002
Supreme Court Awards Decision to SLP
Author Notes
  • Rachel Cohen, is an intern with The ASHA Leader.
    Rachel Cohen, is an intern with The ASHA Leader.×
Article Information
Practice Management / Professional Issues & Training / Regulatory, Legislative & Advocacy / On the Pulse
On the Pulse   |   July 01, 2002
Supreme Court Awards Decision to SLP
The ASHA Leader, July 2002, Vol. 7, 1-20. doi:10.1044/leader.OTP.07132002.1
The ASHA Leader, July 2002, Vol. 7, 1-20. doi:10.1044/leader.OTP.07132002.1
Speech-language pathologist Debra Moran was wrapping up a co-treatment session with an occupational therapist and apatient when her cell phone rang. No number showed on her caller ID screen, which usually means the call is from the media or her lawyer.
It was June 20 and the Winfield, IL, SLP had been waiting for this call since Jan. 16, when the U.S. Supreme Court heard her case involving the right of patients to an independent second medical opinion when a health maintenance organization (HMO) denies medical benefits.
Moran took the call. It was a reporter from CBS News, requesting a reaction to the Supreme Court ruling. She said she hadn’t yet heard about it. The reporter informed her of the decision in what is likely to be the only patients’ rights case decided this year: “5-4, you won...”
Moran’s legal battle began in 1995 when she began to feel pain and numbness in her right arm and shoulder. In her private practice, which focuses on serving children and adults who use augmentative and alternative communication, the increasing pain made it difficult for her to drive, type, and talk on the phone. She was forced to decrease her caseload as her arm became nearly paralyzed.
When Moran saw a primary care physician within her insurance provider’s network to seek treatment, she had no idea that it would launch a series of surgeries and court cases that would take her to the Supreme Court. “This is sheer justification for that long fight,” she said. “I want to educate people and get the word out that they can start getting their independent reviews from the moment they get that denial letter.”
The court ruled that HMOs regulated by state laws are a form of insurance as well as an employee benefit plan. The HMO “…provides health care, and it does so as an insurer,” Justice David H. Souter wrote for the majority that also included Justices John Paul Stevens, Sandra Day O’Connor, Ruth Bader Ginsburg, and Stephen G. Breyer. The decision preserves similar laws approved by 42 states and the District of Columbia in response to the national patients’ rights movement.
The Supreme Court decision determines the extent to which state laws regulating managed care are overruled by the federal Employee Retirement Income Security Act (ERISA), which was designed to provide regulation of employee benefit plans. Passed in 1974 before managed care became prevalent, the law does not address an insurer’s responsibility to provide independent medical reviews. The law does not require “an either-or choice between health care and insurance in deciding a preemption question,” Souter wrote.
Illinois law has offered an independent review provided by a specialist selected by the HMO and the primary-care physician since 1987. Under that state law, if the outside reviewer says the service is medically necessary then the HMO must cover it. Moran’s insurer, Rush Prudential HMO, refused to pay for her surgery after an independent medical review deemed it necessary, and said that Moran could have been treated by a cheaper procedure.
Eventually, Moran underwent a 14-hour microreconstructive operation for brachial plexopathy that saved her career and quality of life. This cost $95,000 in advance, which Moran paid for by borrowing from her husband’s 401(k) plan, her mother-in-law, and by maxing out credit cards. Almost a year later, the state court ordered Rush Prudential HMO to provide her with an independent medical review, which it deemed medically necessary.
The HMO won in a federal district court, which agreed with the firm that the Illinois law was preempted by ERISA. But the U.S. Court of Appeals in Chicago sided with Moran, and Rush Prudential HMO appealed to the U.S. Supreme Court.
“I knew that we were right and that justice would prevail,” Moran said.
The American Medical Association and 32 states filed amicus briefs in support of Moran’s case. States are increasingly backing laws that give patients the right to ask for a medical review, and her case has been closely watched for its possible impact on the stalemated debate in Congress over a patients’ bill of rights.
“People really need to find out what type of plan they have whether self-insured or fully insured,” Moran said. “States have independent laws, and there is still a need for a uniform law for independent review across the board.”
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July 2002
Volume 7, Issue 13