Lower Court Holding
Decision of the Seventh Circuit U.S. Court of Appeals
Section 4-10 of Illinois’ Health Maintenance Organization Act requires health maintenance organizations (HMOs) to submit to an independent physician review when there is a disagreement over whether a course of treatment is medically necessary between a patient’s primary care physician and the HMO. In the event that the independent reviewer determines that the treatment is necessary, the HMO is required under Section 4-10 of the HMO Act to cover the treatment. The comprehensive scope of the Employee Retirement Income Security Act (ERISA) extends to the regulation of employee welfare benefit plans providing "medical, surgical, or hospital care or benefits" for…
