2331-S2 AMH ALEX SCHL 64

2SHB 2331 - H AMD 470 FAILED 2-14-00

By Representative Alexander

     On page 17, line 35, strike all of subsection 7 and insert the following:

A(7)(a) An enrollee or an enrollee=s representative may not maintain a cause of action under this section against a health carrier unless:

     (i) The affected enrollee or the enrollee=s representative has sought independent review of the health care treatment decision under section 11 of the act;

     (ii) The independent review organization has overturned the carrier=s decision to modify, discontinue, or deny a health service; and

     (iii) The carrier=s decision to modify, discontinue, or deny an otherwise covered health service caused substantial harm to the enrollee. As used in this subsection, Asubstantial harm@ means loss of life, loss or significant impairment of limb or bodily function, significant disfigurement, severe or chronic pain or disease, or substantial mental impairment that results in the inability of the enrollee to meet his or her basic needs.

     (b) This subsection (7) does not prohibit an enrollee from pursuing injunctive relief or declaratory judgement prior to completing independent review if the time required to complete independent review would place the enrollee=s life or health in serious jeopardy.@

EFFECT: Allows a person to maintain a cause of action only if the independent review rules against a carrier=s decision to modify, discontinue, or deny a health service.