Cite as: 536 U. S. 355 (2002)
Opinion of the Court
physicians, and the like. But this is as far as the resemblance to arbitration goes, for the other features of review under § 4-10 give the proceeding a different character, one not at all at odds with the policy behind § 1132(a). The Act does not give the independent reviewer a free-ranging power to construe contract terms, but instead, confines review to a single term: the phrase "medical necessity," used to define the services covered under the contract. This limitation, in turn, implicates a feature of HMO benefit determinations that we described in Pegram v. Herdrich, 530 U. S. 211 (2000). We explained that when an HMO guarantees medically necessary care, determinations of coverage "cannot be untangled from physicians' judgments about reasonable medical treatment." Id., at 229. This is just how the Illinois Act operates; the independent examiner must be a physician with credentials similar to those of the primary care physician, 215 Ill. Comp. Stat., ch. 125, § 4-10 (2000), and is expected to exercise independent medical judgment in deciding what medical necessity requires. Accordingly, the reviewer in this case did not hold the kind of conventional evidentiary hearing common in arbitration, but simply received medical records submitted by the parties, and ultimately came to a professional judgment of his own. Tr. of Oral Arg. 30-32.
Once this process is set in motion, it does not resemble either contract interpretation or evidentiary litigation before a neutral arbiter, as much as it looks like a practice (having nothing to do with arbitration) of obtaining another medical opinion. The reference to an independent reviewer is similar to the submission to a second physician, which many health insurers are required by law to provide before denying coverage.13
The practice of obtaining a second opinion, however, is far removed from any notion of an enforcement scheme, and
13 See, e. g., Cal. Ins. Code Ann. § 10123.68 (West Supp. 2002); Ind. Code § 27-13-37-5 (1999); N. J. Stat. Ann. § 17B:26-2.3 (1996); Okla. Admin. Code § 365:10-5-4 (1996); R. I. Gen. Laws § 27-39-2 (1998).
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