Legal Barriers to Insurers' Use of Practice Guidelines. Abstract, ExecutiveSummary and Final Report

摘要

This study analyzes all published court cases since 1960 concerning healthinsurance coverage disputes, in order to predict which factors will influence the acceptance or rejection of medical practice guidelines to determine public or private insurance coverage. We found only 203 cases over 34 years, but the number of cases has increased rapidly since 1980. Patients win over half the time, courts frequently refuse to enforce even specific coverage exclusions, and courts appear to be sympathetic to patients in a serious condition. However, patients prevail much less often in federal appellate courts, and insurers gain a great advantage by writing their contract to give them discretion over the meaning of general coverage language. Insurers lose about the same proportion of cases when they rely on professional consensus statements, on more scientifically based evaluations from various sources, or on no explicit evaluation at all. Consequently, it appears that scientific rigor and adherence to various desirable attributes of guidelines development may still not convince the courts as much as the legalities of the insurance contract or statute, and evidence about what happens to the particular patient in the individual case.