Adopting New Medical Technology (1994) / Chapter Skim
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10. TECHNOLOGY ASSESSMENT, BENEFIT COVERAGE, AND THE COURTS
10. TECHNOLOGY ASSESSMENT, BENEFIT COVERAGE, AND THE COURTS
Pages 117-124
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From page 117... ...
LEGAL HISTORY OF EXPERIMENTAL EXCLUSIONS Insurers originally needed a mechanism to prevent payment for quackery. Treatments rendered by charlatans were not considered medical therapy as defined by medical insurance contracts.
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From page 118... ...
Mary Ader, an attorney for Blue Cross and Blue Shield, summarizes judicial thinking on this matter: First, judges view health plans, particularly insurance companies, not as the private companies they are, but rather as quasi-governmental bodies whose purpose is to distribute societal benefits across the community. Second, judges see subscriber complaints as their opportunity, or even obligation, to distribute a benefit to the individual at no cost to the community at large.
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From page 119... ...
The demand for accountability forced insurers to begin examining standard medical practices. As a professional group, physicians believed they were accountable only to themselves.
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From page 120... ...
The Pirozzi court also examined autologous bone marrow transplantation and ruled that the treatment was not experimental because it was used in major medical centers and published reports in the literature indicated that tumor shrinkage had occurred with the procedure. The court ignored the fact that the medical centers performing the procedure were the same ones conducting research.
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From page 121... ...
Making an exception to an exclusion jeopardizes the entire contract; the insurer is subject to bad faith contract litigation. Conversely, a new technology invented after the contract list publication must be covered until the next contract renewal, regardless of its efficacy.
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Blue Cross and Blue Shield of Maryland (1991) , the insurer excluded treatment not "accepted by the suitable medical specialty practicing in Maryland." While denying an autologous bone marrow transplantation, the insurer cited multiple articles from the medical literature supporting its own position.
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Third, the judiciary must cease creating social policy and writing benefit coverage. The courts served a useful purpose by raising the standards for technology assessment and coverage decisions.
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From page 124... ...
Gerber Products Company Medical Benefits Plan, 728 F
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