Insurance Law Commons^™

Evidence Supporting The Value Of Surgical Procedures: Can We Do Better?, Christopher Robertson, Jonathan Darrow, Willard S. Kasoff

Faculty Scholarship

There is an acknowledged need for higher-quality evidence to quantify the benefit of surgical procedures, yet not enough has been done to improve the evidence base. This lack of evidence can prevent fully informed decision-making, lead to unnecessary or even harmful treatment, and contribute to wasteful expenditures of scare health care resources. Barriers to evidence generation include not only the long-recognized technical difficulties and ethical challenges of conducting randomized surgical trials, but also legal challenges that limit incentives to conduct surgical research as well as market-based challenges that make it difficult for those funding surgical research to recoup investment costs. …

Ideology Meets Reality: What Works And What Doesn't In Patient Exposure To Health Care Costs, Christopher Robertson, Victor Laurion

Faculty Scholarship

U.S. policymakers, scholars, and advocates have long displayed an ideological commitment to exposing insured patients to substantial out-of-pocket expenses. These commitments derive from both overt political ideologies, which favor individual responsibility and oppose redistribution of wealth and risks, as well as more-subtle ideological commitments of academic economists, which link observed patterns of consumption to value-claims about welfare. In this symposium contribution, we document those ideological commitments and juxtapose them with a review of the scientific evidence about the actual effects of patient cost-sharing. We find, as economic theory predicts, that patients exposed to healthcare costs consume less healthcare. However, a …

Regulation Of The Sharing Economy: Uber And Beyond, Jack M. Beermann

Shorter Faculty Works

On January 8, 2016, the Section held a program entitled “Regulation of the Sharing Economy: Uber and Beyond.” I served as moderator of the program, which included four excellent speakers, Nicole Benincasa, Attorney for Uber Technologies, Inc., Bernard N. Block, Managing Principal, Alvin W. Block & Associates, Chicago, Illinois, Randy May, Founder and President, Free State Foundation (and long-time active member of the Section) and Peter Mazer, General Counsel to the Metropolitan Taxicab Board of Trade and former General Counsel to the New York City Taxicab Licensing Commission.

The program began by asking general questions about regulatory issues concerning the …

After Tackett: Incomplete Contracts For Post-Employment Healthcare, Maria O'Brien

Faculty Scholarship

This paper examines the recent U.S. Supreme Court retiree health care decision in Tackett v. M & G Polymers and focuses, in particular, on the ostensibly odd silence with respect to a critical contract term — whether the parties in fact agreed that these benefits were vested. Although the union in Tackett insisted these welfare benefits were clearly intended to vest and the employer now asserts they can be modified at any time, the collective bargaining agreement and supporting documents are ambiguous on this question. This paper examines how and why this “silence” persisted for so many decades and concludes …

Should Patient Responsibility For Costs Change The Doctor-Patient Relationship?, Christopher Robertson

Faculty Scholarship

Copays, deductibles, coinsurance, and reference prices all now expose patients to increasingly larger shares of the costs of health care. Extant research on cost sharing has primarily focused on its impact on patients, their health care spending, and their health outcomes. Scholars have paid much less attention to the question of how patient exposure to health care costs may impact physicians and their relationships with their patients. This Essay is given on the occasion of a symposium motivated by two recent books by David Schenck, Larry Churchill, and Joseph Fanning that highlight the relational aspects of health care ethics. Accordingly, …

A Problem Not Yet Manifest: Gaps In Insurance Coverage Of Medical Interventions After Genetic Testing, Christopher Robertson

Faculty Scholarship

In the past decade, the field of genomics has rapidly changed and expanded.1 With these advancements also come new applications of genomics and genetics to clinical medicine. The information gathered from genetic testing and genome sequencing can reveal a great deal about not only an individual's current health, but his/her future health as well.2 This rapid expansion of scientific and medical capacity is accompanied by rapid changes for law and policy making thoughtful regulation essential. The human genome includes many variations, most of which have no known significance. However, some variants can be the cause of important medical conditions, and …

Scaling And Splitting, New Approaches To Health Insurance, Christopher Robertson

Faculty Scholarship

In the United States, cost-sharing in health insurance coverage has become the primary mechanism for reducing insurance expenditures and, by extension, maintaining affordable coverage. Cost-sharing involves patients making various out-of-pocket (OOP) payments for their own health care aside from whatever the insurer pays. As a patient’s spending on health care grows month by month in any given year of coverage, she moves through three different “zones” of insurance, from no insurance, to partial insurance, and finally to full insurance.

Central Falls Retirees V. Bondholders: Assessing Fear Of Contagion In Chapter 9 Proceedings, Maria O'Brien

Faculty Scholarship

Modern Chapter 9 litigation has been characterized by extraordinary protections for municipal bondholders, and Central Falls is no exception. Although not well understood by politicians, fear of contagion has encouraged the adoption of legal arrangements that have limited the bankruptcy courts’ ability to include bondholders in the cost of restructuring municipal debt. This preference for bondholders (and, by extension, their insurers) has meant increased misery for taxpayers and retirees. Given that all of these actors appear to have been complicit to some degree in the creation and maintenance of the fiscally imprudent conditions that triggered bankruptcy and that evidence of …

Do Damages Caps Reduce Medical Malpractice Insurance Premiums?: A Systematic Review Of Estimates And The Methods Used To Produce Them, Kathryn Zeiler, Lorian Hardcastle

Faculty Scholarship

Despite common claims made in policy debates, the theoretical connection between tort reform and medical malpractice insurance premiums is ambiguous. Simple models suggest reforms such as statutory damages caps reduce premiums. More elaborate models that account for changes in physician behavior suggest caps might increase or have no impact on premiums. A number of empirical studies have been conducted to estimate the impacts of caps on premiums, and several qualitative literature reviews have attempted to draw general conclusions from the literature. No review, however, has offered a comprehensive and systematic analysis of the full set of empirical studies. This chapter …

Disclosure To The Rescue: A Conceptual Framework For Retained Asset Accounts, Maria O'Brien

Faculty Scholarship

RAAs (Retained Asset Accounts) are a life insurance innovation that is likely of small value to most beneficiaries. In many cases, it will make the most financial sense for a beneficiary to write a check to himself for the entire policy proceeds and deposit those funds into an insured bank account. Some beneficiaries, however, may find the RAA device helpful. It is impossible to anticipate the myriad circumstances that beneficiaries may face at the time of an insured's death. As long as insurers provide full and clear disclosure (which ERISA fiduciary standards demand), consumers should remain free to choose an …

The Affordable Care Act And Health Promotion: The Role Of Insurance In Defining Responsibility For Health Risks And Costs, Wendy K. Mariner

Faculty Scholarship

This article examines whether insurance is an appropriate mechanism for improving individual health or reducing the cost of health care for payers. The Affordable Care Act contains implicit standards for allocating responsibility for health, especially in provisions encouraging health promotion and wellness programs. A summary of the accumulating evidence of the effects of such programs suggests that wellness programs have been somewhat more effective in making people feel better than in reducing costs. Health promotion should be encouraged, because health is valuable for its own sake. Insurance is not well suited to improve health or manage behavioral risks to health; …

Health Reform: What's Insurance Got To Do With It? Recognizing Health Insurance As A Separate Species Of Insurance, Wendy K. Mariner

Faculty Scholarship

Health insurance can be, and to a large extent already is, a separate species of insurance. This article describes the different views of insurance that made health reform contentious. It argues that the goals of health reform are incompatible with conventional views of insurance. Nonetheless, reforming health insurance to achieve those goals does not require as dramatic shift as some might think, because health insurance has already become primarily a means of paying for health care, rather than a simple risk spreading device for specified losses.

Bonding Bankers: Notes Toward A Governance Approach To Risk Regulation, Frederick Tung

Faculty Scholarship

Important regulatory failures have been identified in the wake of the recent financial crisis, and comprehensive regulatory reform has been much on the minds of policymakers. Reform proposals call for a number of significant changes to the scope and structure of financial regulation to address systemic risk. With banking regulation, however, the twin tools of capital requirements and external supervision seem to remain the dominant regulatory levers. In this short discussion, I introduce the contours of an important supplement to the existing approach, a governance approach that uses bank executives' compensation arrangements as a policy lever. I propose that bank …

Let The Securities And Exchange Commission Outsource Enforcement By Litigation: A Proposal, Tamar Frankel

Faculty Scholarship

The stories of Stanford's suspected Ponzi scheme, and Madoff s proven scheme, as well as the Securities and Exchange Commission's lenient settlements with very large suspected violators, and its focus on the numerous, small accused, have raised questions about the Commission's enforcement resources. This Article suggests that the Commission outsource civil cases against very large defendants when the examination of the defendant finds signs of wrongdoing under the securities acts. The Commission already outsources two types of legal services and the United States government practices extensive outsourcing. This article suggests that with appropriate limitations and controls outsourcing of enforcement litigation …

Federalization Snowballs: The Need For National Action In Medical Malpractice Reform, Abigail Moncrieff

Faculty Scholarship

Because tort law generally and healthcare regulation specifically are traditional state functions and because medical, legal, and insurance practices are highly localized, legal scholars have long believed that medical malpractice falls within the states' exclusive jurisdiction and sovereignty. Indeed, this view is so widely held that modern legal scholarship takes it for granted. Articles on general federalism issues use medical malpractice as an easy example of a policy in which federal intervention lacks functional justification, and articles that focus on federalization of other tort reforms use medical malpractice as an easy foil, pointing out that the uniformity interest that justifies …

Malpractice Payouts And Malpractice Insurance: Evidence From Texas Closed Claims, 1990-2003, Charles Silver, Kathryn Zeiler, Bernard Black, David Hyman, William Sage

Faculty Scholarship

Background. This study is the first to quantify physicians' malpractice insurance limits. It also examines the connection between policy size and payments on claims, including the frequency of settlement at the policy limits and the frequency of out-of-pocket payments.

Methods. Statistical analyses using data collected by the Texas Department of Insurance (TDI) covering all insured medical malpractice claims against physicians closed between 1990 and 2003 with payment of $25,000 or more (measured in 1988 dollars).

Results. Contrary to conventional wisdom, per-occurrence limits of $500,000 or less were as common as $1 million limits. Nominal policy size was stable over time, …

Physicians' Insurance Limits And Malpractice Payments: Evidence From Texas Closed Claims, 1990-2003, Kathryn Zeiler, Charles Silver, Bernard Black, David Hyman, William Sage

Faculty Scholarship

Physicians' insuring practices influence their incentives to take care when treating patients, their risk of making out-of-pocket payments in malpractice cases, and the adequacy of compensation available to injured patients. Yet, these practices and their effects have rarely been studied. Using Texas Department of Insurance data on 9,525 paid malpractice claims against physicians that closed 1990-2003, we provide the first systematic evidence on levels of coverage purchased by physicians with paid liability claims and how those levels affect out-of-pocket payments and patient compensation. We find that these physicians carried much less insurance than is conventionally believed, that their real primary …

The Supreme Court's Limitation Of Managed-Care Liability, Wendy K. Mariner

Faculty Scholarship

This article summarizes and critiques the U.S. Supreme Court's decision in Aetna Health Inc. v. Davila, which limited managed care organizations' liability for negligent decisions about the care of patients in private employer-sponsored health plans governed by ERISA. It contrasts the Court's dichotomous view of health benefit plans, in which insurers administer contracts and treating physicians make medical judgments, with the more complicated relationships that affect decisions about both coverage and treatment.

Can Consumer-Choice Plans Satisfy Patients? Problems With Theory And Practice In Health Insurance Contracts, Wendy K. Mariner

Faculty Scholarship

Much scholarship has considered whether health care - and insurance - should be distributed by voluntary contract or subject to government standards or regulation. Contracts will likely play a key distributive role in any future health care system. Yet we do not fully understand where private contracting does and does not work to further the goals of equitable access to affordable care. This article examines the role of health insurance policies in defining and enforcing access to medical care, focusing on private employment-based group health benefit plans. It describes models of consumer choice health plans and critiques their capacity for …

Securitizing Insurance Risks, Tamar Frankel, Joseph W. Laplume

Faculty Scholarship

This Article analyzes and evaluates the legal problems that have arisen in connection with this rapidly developing insurance risk securitization. The first part of the Article deals with legal issues concerning the SPVs that undertake insurance and reinsurance contracts with ceding insurers and the other parties to the transaction. The Article addresses the dilemma in choosing the laws applicable to SPVs, the bonds they issue, and the persons and entities that form part of the securitization transaction. These laws involve state insurance laws, bankruptcy and tax laws, the Investment Company Act of 1940 and the Commodity Exchange Act of 1934, …

Evaluating The Case For Social Security Reform: Elderly Poverty, Paternalism And Private Pensions, Maria O'Brien

Faculty Scholarship

This Article considers the many arguments currently being made in favor of Social Security pension reform and evaluates each of them in terms of the principal Congressional goal of the program-the elimination of elderly poverty-as well as more recent goals that have been articulated by subsequent commentators such as a reduction in government paternalism and the maximization of retirement income. The Article begins with a short history of the public pension program in the United States and considers at length the details of the various reform proposals that currently enjoy support. In addition it examines the enormously regressive tax structure …

Some Preliminary Thoughts On The Deregulation Of Insurance To Advantage The Working Poor, Maria O'Brien

Faculty Scholarship

The regulatory framework in which employee benefits products are marketed and consumed by individuals and groups seeking to reduce exposure to covered events creates a set of background rules. These rules influence the way in which insurance products are developed and impact the number of people who will enjoy the protection these insurance products afford. This means that every proposal to regulate an employment related insurance product likely will affect both the quality and quantity of insurance available to consumers. For example, over the past decade, as the public and professionally-interested parties have grappled with the insurance implications of the …

Insurance Risk Classification After Mcgann: Managing Risk Efficiently In The Shadow Of The Ada, Maria O'Brien

Faculty Scholarship

A significant part of the health insurance debate which gripped the country during the first two years of President Clinton's administration focused on the critical shortage of employer-sponsored health insurance for disabled, br high risk, employees. Indeed, President Clinton's promise of universal access in connection with the promotion of his health care plan is apparently designed to ensure that the increasingly popular employer practice of excluding high risk employees becomes obsolete. In the meantime, while the merits of the Clinton plan and its competitors are debated, individuals like John McGann-working and insured--continue to discover that like their health, their insurance …

Bank Powers To Sell Annuities, Tamar Frankel

Faculty Scholarship

The conflict over turf between the banking industry and the insurance agents has heated up again. In the 1993 case Variable Annuity Life Ins. Co. v. Clarke, ¹ the Fifth Circuit held banks have no power to sell fixed annuities issued by insurance companies in cities with more than 5,000 inhabitants. On June 6, 1994, the Supreme Court granted certiorari to review the decision. ³ Both the Clinton Administration and members of Congress are considering steps toward resolving this issue. Concerned that the flight of high-quality borrowers from the banking system has rendered bank lending increasingly risky, the Comptroller of …

The Economics And Politics Of Emergency Health Care For The Poor: The Patient Dumping Dilemma, Maria O'Brien

Faculty Scholarship

As the numbers of uninsured mount⁴ because of job dislocations, exhaustion of benefits, and unaffordably high premiums, the incidence of "dumping" by private hospitals is, predictably, on the rise. Dumping occurs when a hospital, in violation of federal or state law, transfers an emergency patient to another (usually public) hospital or simply refuses any treatment based on the patient's inability to pay.5 In addition to the completely uninsured, favorite dumping targets include Medicare and Medicaid patients, AIDS patients, and cancer patients whose therapy may cost more than the maximum reimbursement under private insurance.

Dumping is merely a part of …

Mengele's Birthmark: The Nuremberg Code In United States Courts, George J. Annas

Faculty Scholarship

Experimentation on human beings is so difficult to justify that the attempt is seldom even made. Usually its justification is simply assumed, and vague notions of progress or national emergency are suggested as sufficient rationales. The United States, a society dedicated to both progress and human rights, has been profoundly ambivalent about human experimentation. On the one hand, we have consistently argued in our ethical codes that the rights and welfare of research subjects must be protected; on the other hand, we have consistently used perceived emergencies, both national and medical, as an excuse to jettison individual rights and welfare …

Variable Life Insurance, Tamar Frankel

Faculty Scholarship

No abstract provided.

Medical Malpractice Litigation Under National Health Insurance: Essential Or Expendable, George J. Annas

Faculty Scholarship

"Medical malpractice" denotes the basis for a civil action brought by a patient against a physician for injuries resulting from negligence. The current method for compensating victims of these occurrences is primarily a fault-and-liability insurance system. The first principle of tort liability is that the party at fault pays for the damage inflicted upon an innocent victim. Whether a doctor is at fault is determined in an adversary proceeding, with both the doctor and the patient represented by counsel. The triers of fact have the task of ascertaining whether the defendant was at fault, and if so, what compensation he …

Regulation Of Variable Life Insurance, Tamar Frankel

Faculty Scholarship

On November 29, 1971 the American Life Convention and Life Insurance Association of America filed a petition with the Securities and Exchange Commission (SEC) to exempt certain variable life insurance policies and separate accounts funding them from the provisions of the federal securities acts.¹ The petition had been preceded by informal negotiations by the insurance industry for a decision by the SEC "not to assert jurisdiction" over such policies and accounts.² The Commission's staff declined to recommend primarily because the staff felt that other interested parties ought to be heard before a determination was made which might adversely …