Utilization review and managed health care liability.
This article explores the development of jurisprudence interpreting application of the Employee Retirement Income Security Act of 1974 to patient care denials by managed care. It identifies quality-of-care protections for patient care under present federal law. If an insurance company utilization review denies care based on patient-specific reasoning, then the patient may have recourse against the utilization review on the basis of a state law claim of malpractice grounded in medical decision-making by the insurance company.
Spector
Richard A
RA
Middleberg, Riddle & Gianna, New Orleans, LA 70170, USA. rspector@midrid.com
D003657:Decision Making; D019461:Employee Retirement Income Security Act; D006279:Health Maintenance Organizations / Q000331:legislation & jurisprudence; D006801:Humans; D008318:Malpractice / Q000331:legislation & jurisprudence*; D008329:Managed Care Programs / Q000331:legislation & jurisprudence*; D016079:Refusal to Treat / Q000331:legislation & jurisprudence; D013781:Texas; D014481:United States; D014600:Utilization Review / Q000331:legislation & jurisprudence*