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Get Your Claim Paid: Guidelines from the Other Coast

In California, managed care health plans, which were battered in the court of public opinion, have lost ground in the court of legal opinion as well.

Several key judicial rulings during the late 1990s -- coupled with a new state law and heightened scrutiny of health insurance companies by the chief justice of the California Supreme Court -- promise to provide patients with significant new ammunition when they wind up in disputes with their HMOs.

Some of these developments have gained considerable attention. Others have gone more unnoticed. When taken together, experts say, they mark an unmistakable power shift in favor of consumers in the continuing struggle to sort out a critical question: Does the playing field need to be leveled when patients battle their health plans over denied benefits?

"The pendulum has reached its peak and is swinging back in the other direction in favor of the insured," says Jay Taylor, a Los Angeles attorney, who just a few weeks ago won the latest major court ruling that bolsters the rights of plan members.

Taylor's victory came when the state's Second District Court of Appeals in Los Angeles ruled that he could proceed with his efforts to establish a class-action arbitration against Blue Cross of California. The insurance company, a unit of Wellpoint Health Networks Inc., had argued that it should be able to handle disputes one at a time -- and not have to face a larger group of patients who had banded together.

The court's decision is important because it will allow many more health plan enrollees to pool their resources for what might otherwise be prohibitively expensive arbitration proceedings.

Under the arbitration system, conflicts that arise between the patient and the health plan are taken to an individual or panel of arbitrators for binding resolution.

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