Initially, Mr. H was denied coverage because he did not get a referral from his primary physician to see a specialist. The original treatment to which Mr. H's primary care physician was subjecting Mr. H was 1. not effective and 2. The physician suggested a radical amputation for his condition while the second opinion Mr. H sought suggested a much less radical procedure which would allow Mr. H to retain his mobility. It could be logically argued that had Mr. H not gone 'out of network' he would have suffered substantial medical harm. Furthermore, while the HMO cited as a reason for denial of claim a provision in the plan documents that prevents referrals outside the plan's network when the network's physicians have the capability to perform the required procedure, Mr. H seems to have legitimate questions about his in-network physician's competence to perform the procedure. Unfortunately for Mr. H, however, he has far less legal ground on which to stand than he would, had he been covered under either form of government insurance. Denial of coverage by an HMO is not regarded as a medical decision. "If an HMO correctly concludes that a particular...
The proximate cause would be the plan's failure to cover the requested treatment….plaintiffs can no longer argue that HMO coverage and payment decisions are equal to medical treatment, however, and sue for tort recovery under state medical negligence laws, when the patient's sole connection with the HMO is that it determines scope of coverage and pays for benefits" under the private insurance plan (Bacon 2004).
Tort Reform President Bush came into the White House with a history as a 'tort reformer.' True to his record, the President backed a 'tort reform' bill last year that was passed by the House of Representatives but floundered in a Democratic controlled Senate. The President has recently renewed his call for the legislature to approve a tort reform bill that relates mainly to medical malpractice. It remains to be seen
Fault: An Alternative to the Current Tort-Based System in England and Wales The United Kingdom statistics regarding claims THE NATIONAL HEALTH SYSTEM OBSTACLES TO DUE PROCESS THE CASE FOR REFORM THE REGULATORY ENVIRONMENT THE RISING COST OF LITIGATION LORD WOOLF'S REFORMS MORE COST CONTROLS THE UNITED STATES PAUL'S PULLOUT THE INSURANCE INDUSTRY TORT REFORM IN AMERICA FLEEING PHYSICIANS STATISTICS FOR ERROR, INJURY AND DEATH THE CALL FOR REFORM IN 2003: A FAMILIAR REFRAIN THE UNITED STATES SITUATION, IN SUMMARY NEW ZEALAND CASE STUDIES THE SWEDISH SCHEME COMPARISON: WHICH SYSTEM IS
conventional wisdom has always stated that hedging strategies and life insurance are ill-matched partners. The belief has always been that the philosophical motivation behind employing one is diametrically opposed to that of the other. Insurance companies have traditionally shunned the use of derivatives as a hedging strategy because the insurance industry is all about risk management and hedging instruments required too much specialized knowledge and too many risks to
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