Rules of Medical Necessity
Health insurance has long been understood to cover most forms of "medically necessary" health care. But who gets to decide whether particular medical interventions for individual patients are indeed "medically necessary" and hence covered? Since the 1980s, health insurers have attempted to reserve this authority for themselves. For just as long, state and federal laws have policed insurers' medical necessity determinations to ensure that they do not put profits ahead of patients. In his talk, Professor Schwarcz will explore how health insurers are increasingly undermining these legal constraints on their coverage determinations by formally incorporating into their insurance policies incredibly detailed and specific rules for when particular types of care are medically necessary for particular types of patients. He will also explore whether and how federal and state actors can push back on these insurer efforts to avoid legal oversight of their medical necessity determinations. Professor Schwarcz's talk will be based on his draft article, Rules of Medical Necessity, which is co-authored with Professor Amy Monahan and is forthcoming in the Iowa Law Review.
Professor Daniel Schwarcz is an award-winning teacher and scholar. His research focuses on a broad range of issues in insurance law and regulation, spanning systemic risk, regulatory federalism, consumer protection, employer-sponsored health insurance, and insurance coverage litigation. In 2017, the American Law Institute awarded Schwarcz its highly selective Early Career Scholars Medal, which recognizes one or two “outstanding law professors whose work is relevant to public policy and has the potential to influence improvements in the law relevant to the real world.” He has also been awarded the Liberty Mutual Prize, which is given annually for the most outstanding article on property and casualty insurance law.
Schwarcz teaches courses on contract law, insurance law, the regulation of financial institutions, commercial law, health care regulation and finance, and judicial opinion writing. He has twice received teaching awards at the Law School, in 2008 and 2012. Read his full speaker biography online.
A brief reception will follow the lecture from approximately 5 to 6 p.m. in Auerbach Commons on the plaza level of Mondale Hall.