[ Search ] [ Legislation ] [ Bill Summary ]
[ Home ] [ Back ] [ Bottom ]
| [ Introduced ] | [ House Amendment 001 ] |
90_HB3265ham002
LRB9009287JSmbam02
1 AMENDMENT TO HOUSE BILL 3265
2 AMENDMENT NO. . Amend House Bill 3265, AS AMENDED,
3 by inserting immediately below the last line of Section 105
4 the following:
5 "Section 107. Health care entity liability.
6 (a) In this Section:
7 "Appropriate and medically necessary" means the standard
8 for health care services as determined by physicians and
9 health care providers in accordance with the prevailing
10 practices and standards of the medical profession and
11 community.
12 "Enrollee" means an individual who is enrolled in a
13 health care plan, including covered dependents.
14 "Health care plan" means any plan whereby any person
15 undertakes to provide, arrange for, pay for, or reimburse any
16 part of the cost of any health care services.
17 "Health care provider" means a person or entity as
18 defined in Section 2-1003 of the Code of Civil Procedure.
19 "Health care treatment decision" means a determination
20 made when medical services are actually provided by the
21 health care plan and a decision that affects the quality of
22 the diagnosis, care, or treatment provided to the plan's
23 insureds or enrollees.
-2- LRB9009287JSmbam02
1 "Health insurance carrier" means an authorized insurance
2 company that issues policies of accident and health insurance
3 under the Illinois Insurance Code.
4 "Health maintenance organization" means an organization
5 licensed under the Health Maintenance Organization Act.
6 "Managed care entity" means any entity that delivers,
7 administers, or assumes risk for health care services with
8 systems or techniques to control or influence the quality,
9 accessibility, utilization, or costs and prices of those
10 services to a defined enrollee population, but does not
11 include an employer acting on behalf of its employees or the
12 employees of one or more subsidiaries or affiliated
13 corporations of the employer.
14 "Physician" means: (1) an individual licensed to practice
15 medicine in this State; (2) a professional association,
16 professional service corporation, partnership, medical
17 corporation, or limited liability company, entitled to
18 lawfully engage in the practice of medicine; or (3) another
19 person wholly owned by physicians.
20 "Ordinary care" means, in the case of a health insurance
21 carrier, health maintenance organization, or managed care
22 entity, that degree of care that a health insurance carrier,
23 health maintenance organization, or managed care entity of
24 ordinary prudence would use under the same or similar
25 circumstances. In the case of a person who is an employee,
26 agent, ostensible agent, or representative of a health
27 insurance carrier, health maintenance organization, or
28 managed care entity, "ordinary care" means that degree of
29 care that a person of ordinary prudence in the same
30 profession, specialty, or area of practice as such person
31 would use in the same or similar circumstances.
32 (b) A health insurance carrier, health maintenance
33 organization, or other managed care entity for a health care
34 plan has the duty to exercise ordinary care when making
-3- LRB9009287JSmbam02
1 health care treatment decisions and is liable for damages for
2 harm to an insured or enrollee proximately caused by its
3 failure to exercise such ordinary care.
4 (c) A health insurance carrier, health maintenance
5 organization, or other managed care entity for a health care
6 plan is also liable for damages for harm to an insured or
7 enrollee proximately caused by the health care treatment
8 decisions made by its:
9 (1) employees;
10 (2) agents;
11 (3) ostensible agents; or
12 (4) representatives who are acting on its behalf
13 and over whom it has the right to exercise influence or
14 control or has actually exercised influence or control
15 that results in the failure to exercise ordinary care.
16 (d) The standards in subsections (b) and (c) create no
17 obligation on the part of the health insurance carrier,
18 health maintenance organization, or other managed care entity
19 to provide to an insured or enrollee treatment that is not
20 covered by the health care plan of the entity.
21 (e) A health insurance carrier, health maintenance
22 organization, or managed care entity may not remove a
23 physician or health care provider from its plan or refuse to
24 renew the physician or health care provider with its plan for
25 advocating on behalf of an enrollee for appropriate and
26 medically necessary health care for the enrollee.
27 (f) A health insurance carrier, health maintenance
28 organization, or other managed care entity may not enter into
29 a contract with a physician, hospital, or other health care
30 provider or pharmaceutical company which includes an
31 indemnification or hold harmless clause for the acts or
32 conduct of the health insurance carrier, health maintenance
33 organization, or other managed care entity. Any such
34 indemnification or hold harmless clause in an existing
-4- LRB9009287JSmbam02
1 contract is hereby declared void.
2 (g) Nothing in any law of this State prohibiting a
3 health insurance carrier, health maintenance organization, or
4 other managed care entity from practicing medicine or being
5 licensed to practice medicine may be asserted as a defense by
6 the health insurance carrier, health maintenance
7 organization, or other managed care entity in an action
8 brought against it pursuant to this Section or any other law.
9 (h) In an action against a health insurance carrier,
10 health maintenance organization, or managed care entity, a
11 finding that a physician or other health care provider is an
12 employee, agent, ostensible agent, or representative of the
13 health insurance carrier, health maintenance organization, or
14 managed care entity shall not be based solely on proof that
15 the person's name appears in a listing of approved physicians
16 or health care providers made available to insureds or
17 enrollees under a health care plan.
18 (i) This Act does not apply to workers' compensation
19 insurance coverage subject to the Workers' Compensation Act.
20 (j) This Act applies only causes of action that accrue
21 on or after the effective date of this Act.
22 (k) The determination of whether a procedure or
23 treatment is medically necessary must be made by a physician.
24 (l) If the physician determines that a procedure or
25 treatment is medically necessary, the health care plan must
26 pay for the procedure or treatment.".