Subject: Court Invalidates Denial of Benefits for Health Plan Member With AIDS
From: [email-masked]
Date: Tue, 19 Dec 1995 12:45:29 -0500

LAMBDA LEGAL DEFENSE AND EDUCATION FUND	

FOR IMMEDIATE RELEASE		 Contact: Catherine Hanssens
Wednesday, December 13, 1995		 (212) 995-8585

Federal Appeals Court Invalidates Denial of Benefits
for Health Plan Member With AIDS

Court Rejects HMO's Refusal to Pay for AIDS Care Outside Service Area

"An AIDS diagnosis can have a wide range of physical consequences that vary
with each individual, hardly a basis for the broad conclusion that
hospitalization becomes automatically foreseeable," noted Catherine Hanssens,
AIDS Project Director at Lambda Legal Defense and Education Fund, which
joined the Whitman-Walker Clinic in a brief on behalf of Bernstein.
  CapitalCare denied payment of Bernstein's New York hospitalization on the
basis that Bernstein's AIDS diagnosis, and his recent treatment history, made
his hospitalization for CNS lymphoma, a form of brain cancer, foreseeable.  
 
The Fourth Circuit Court of Appeals, which covers Maryland, North and South
Carolina, Virginia and West Virginia, acknowledged that persons with AIDS
undergo widely divergent courses of the disease. The court wrote that "the
foreseeability of a particular illness depends on myriad factors such as the
patients' age, the severity of the disease, and prior history with the
particular illness.  Such complex medical determinations are peculiarly
within the ken of medical professionals, not federal judges."  CapitalCare's
medical director, a pediatrician with no specialized training in AIDS, was
the only physician who participated in the decision to deny benefits to
Bernstein, the court pointed out, and the information available to make that
decision simply wasn't adequate.
	
The case now goes back to CapitalCare, which must gather and review
sufficient evidence to make a determination as to whether Bernstein's
treatment for CNS lymphoma was reasonably foreseeable or otherwise covered
under the benefits plan.

Hanssens observed that the decision was important in part for the quality of
evidence  required to support the conclusion that an illness was foreseeable.
 "A broad ruling on what constitutes a foreseeable need for care, with an
AIDS diagnosis and an out-of-town hospitalization for any condition
whatsoever used as reason to deny benefits for an HMO member, would make it
virtually impossible for a person living with AIDS to travel.  CapitalCare's
decision would have required a person with AIDS to remain home-bound and
isolated from family and friends in order to ensure continuing medical
coverage." 

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