Review Article

Utilization Review and Managed Health Care Liability

Authors: Richard A. Spector, MD, JD

Abstract

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.

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References

1. Portions of this article are excerpted from Spector RA, Managed Healthcare Liability Issues, 32Cumb L Rev 311 (2002).
 
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4. Wickline v State, 239 Cal Rptr 805, 825 (1986).
 
5. The Employee Retirement Income Security Act of 1974 § 1144(A).
 
6. Shaw v Delta Airlines, Inc, 43 US 85 (1983).
 
7. New York State Conference of Blue Cross and Blue Shield Plans v Travelers Insurance Company, 514 US 645 (1995).
 
8. New York State Conference, 514 US at 661 (1995).
 
9. New York State Conference, 514 US at 657 (1995).
 
10. Pegram v Herdrich, 530 US 211 (2000).
 
11. Tex Civ Prac & Rem Code, § 88.0022.003 (Vernon Suppl 2002).
 
12. Corporate Health Insurance, Inc v Texas Department of Insurance, 215 F3d 526 (5th Cir 2000).
 
13. Corporate Health, 215 F3d at 536.
 
14. Rush Prudential v Moran, 122 S Ct 2151 (2002).
 
15. Ciccio v Vytra Healthcare, 2003 US App Lexis 2925.