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Discover the key to HMO bad-faith cases: effective discovery will unlock the potential of your client's bad-faith claim against a managed-care health insurer.

Article Excerpt
Plaintiff lawyers must have a sound approach to discovery to effectively litigate bad-faith cases against health maintenance organizations (HMOs). Discovery will establish whether there was a critical delay in authorization, an improper basis for denial, or a lack of proper investigation, all of which demonstrate bad-faith conduct by the HMO.

As always, begin by obtaining all the relevant documents. Several will be critical in every HMO case.

Utilization-review file. This is the equivalent of an insurance claim file in a traditional bad-faith case. Although the information in the file is complex and may be difficult to sort through and digest, doing so is worth the time and effort.

The term "utilization review" refers to the process the HMO or its agents use when deciding whether to approve or deny care to a plan member. The utilization review file serves as a record of every person who was involved in handling the requests for treatment--it shows what decisions were made, who made them, and why. This will be the most telling evidence you obtain in discovery.

As a whole, the utilization review file reflects the attitude the insurer displayed toward its insured. It may show an insurer that gave the claimant the benefit of the doubt and an adjuster who...

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