How Courts View Medical Issues

Health maintenance organizations occasionally find themselves defending their medical decisions in court. These are some of the non-medical factors experts say HMOs may consider when determining to whether to cover sensitive cases:

* Patient demographics. Juries are more likely to be sympathetic to children and women than to middle-age men.

* The illness. A high-profile disease like breast cancer puts an HMO at greater risk in court than colon or prostate cancer.

* Status of the treatment. An HMO is at greater risk if some doctors believe an experimental treatment is worth trying even if chances are slim that it will succeed.

* Precedent. A court is more likely to side with the plaintiff if the HMO has paid for the procedure for other patients.

* Seriousness of the illness. People tend to want HMOs to cover treatments for life-threatening conditions even if their contract is vague.

* Referral. An HMO will be at greater risk as a defendant if a doctor within its own plan recommended the treatment than if an outside physician recommended it.