Related topics

HMO Sued for Misleading Members

October 5, 1999

NEW YORK (AP) _ A federal lawsuit has been filed against Humana Inc., accusing the health maintenance organization of misleading its members about how it makes coverage decisions.

The suit, filed Monday in Miami and seeking class-action status, alleges that Humana didn’t tell customers that cost _ not medical need _ is the main factor behind its decisions on what medical care it approves for members.

``Humana used undisclosed criteria that were unrelated to patients’ medical needs,″ said Joseph Sellers, a partner in the law firm of Cohen, Milstein, Hausfeld & Toll.

Louisville, Ky.-based Humana paid cash bonuses to claim reviewers and had financial arrangements with doctors ``that were clearly designed to reduce the number of patient claims that would be approved,″ the suit says.

Humana officials said they could not comment on the specific allegations because they did not have a copy of the suit. But the company said it planned a vigorous defense.

It also said it supports a process whereby independent physicians determine whether a requested health service is appropriate.

Humana, one of the nation’s largest managed health care companies, has about 6.1 million members in 15 states and Puerto Rico. The suit was filed in federal district court in Miami on behalf of two Riviera Beach, Fla., police officers.

The lawsuit is the first of many that lawyers, including some who gained high profiles in litigation against tobacco companies and Microsoft Corp., are expected to file in coming weeks to challenge coverage decisions of HMOs.

Update hourly