A California man wants to know why his insurance company won't pay for his son's inpatient care at a hospital in Utah — and a federal judge here has ruled in his favor.

Abilio Hernandez claimed in a suit filed in 1999 that he had a right to see the paperwork generated by the denial of payment for treatment his son, Eduardo, received during a two-week stay at Brightway Adolescent Hospital in St. George in 1996.

Hernandez's lawsuit claims that the Employment Retirement Income Security Act of 1974, a federal statute usually referred to as ERISA, requires insurance companies to provide the claims information if it is requested.

U.S. District Judge Dee Benson said Hernandez's appeal of the Prudential Insurance Co. of America's decision requires that the man see those documents.

Benson admitted to attorneys for both Hernandez and Prudential that he had "flipped" from one side to the other in preparing his opinion in the case.

Benson said the 10th Circuit Court of Appeals in Denver has yet to address whether the statute gives patients a right to documents that contain "the criteria used to determine the medical necessity of psychiatric treatment" or the claims reviewer's "identity, credentials and . . . rationale."

Prudential's attorney, Peter W. Billings, argued the documents Hernandez is seeking do not fall under ERISA requirements.

Companies are reluctant to disclose the names of actual reviewers in the claims process, he said, for fear it will leave those employees open to harassment by disappointed customers.

But Hernandez's attorney, Brian King, argued that customer availability to the documents is a "critical" legal question.

"(Insurance companies) have effectively said, if you want them, you must file a lawsuit, because we're not going to give them to you," he said.

Benson denied Prudential's motion for summary judgement, finding the request for the documents to be "necessary for a full and fair review." The case will now proceed toward trial.


E-MAIL: mtitze@desnews.com