GRIJALVA VS. SHALALA 
A Victory for Consumers 

In the summer of 1996, the Consumer Coalition for Quality Health Care organized its members and other consumer groups to join an amicus brief in the case of Grijalva vs. Shalala. The Grijalva case was a class action suit brought by Medicare beneficiaries against the federal government for failure to provide adequate procedural protections when enrollees in a Medicare HMO are denied services.

On October 17, 1996, Judge Alfredo C. Marquez of the Federal District Court in Tucson ruled in favor of the Medicare beneficiary plaintiffs and ordered the Department of Health and Human Services to provide expedited hearings for enrollees that are denied urgently needed medical services by their HMO. The ruling also compels DHHS to require Medicare HMOs to provide adequate notice to beneficiaries when covered services are denied, including the specific basis for the denial.

The New York Times, the Washington Post and the Wall St. Journal all wrote stories on the court ruling.

This court ruling represents a major victory for consumer interests in managed care. The ruling will assist the Consumer Coalition and other consumer groups in advocating for adequate appeals procedures in all managed care plans, including Medicaid and private sector plans.

The following are a list of the groups who signed on to the Amicus brief in the Grijalva case:

                              

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