The case of Rush Prudential HMO, Inc. v Moran orginated when Debra Moran originally file suit against in the HMO in 1997 in Illinois.
After searching for several years for a treatment for a pain in her wrist, Moran consulted with a physician outside of her plan’s network of doctors and underwent a $98,000 surgery.
Rush Prudential shelled out the money for the surgery but challenged Illinois law. The case eventually reached the Court of Appeals in Chicago, which sided with Moran.
Under Illinois’ independent review statute HMOs are required to submit disputed medical coverage determinations to a physician outside of its network for review.