A rebellious House yesterday decided resoundingly to grant Americans a new set of rights to increase their clout against managed-care plans, including broad freedom to sue health plans that deny patients the medical care they want.

The legislation, approved on a vote of 275 to 151, offers the most extensive safeguards among rival plans for protecting people in HMOs that the House considered over the past two days. The bill makes it easier for patients to visit the doctors they prefer, get emergency-room bills paid and receive experimental treatments, as well as giving them new powers to protest HMOs' medical decisions in and out of court.

While the bill's ultimate fate is cloudy, yesterday's vote was a stinging rebuke of the GOP House leadership, which had long opposed opening HMOs to more lawsuits by consumers. Five dozen Republicans broke party ranks to side with all but two Democrats, handing a major victory to President Clinton and other advocates of a tough "patients' bill of rights" that could be enforced.

It appeared that the idea of weakening the power of health maintenance organizations to dictate care is so alluring to voters that it overwhelmed two counterforces: a long, multimillion-dollar campaign by insurance and business interests to block the reforms, and a late sprint by GOP leaders to try to steer their troops toward a middle ground.

The lopsided House vote "shows that America is no longer willing to allow unfeeling practices of some health plans to add to the pain of injury or disease," President Clinton said immediately afterward. But he cautioned, "We still have plenty of work to do before this bill becomes the law of the land."

Whether Americans will ever receive the protections the House conferred yesterday remains uncertain. The ultimate result hinges on whether House conferees can resolve considerable differences with the Senate, which adopted a far more limited patient-protection bill three months ago, and -- even if they can -- whether Clinton is willing to sign the result.

The House version, sponsored by Reps. Charles Whitlow Norwood Jr. (R-Ga.) and John D. Dingell (D-Mich.), allows patients who say they have been injured because their HMO refused to pay for care they believe they need to file lawsuits seeking unlimited damages in state courts. In some instances, they must first take their complaint to one of the new independent grievance panels of doctors that would be created under the legislation to mediate such disputes.

The bill opens the door to new litigation, which has been severely restricted under a 1974 federal law that has allowed people who get health coverage through their employers to sue their insurer only in federal courts and to seek only the monetary value of the treatment they were denied. It resembles laws adopted recently by three states -- Texas, Georgia and California -- that make it easier for patients to sue HMOs.

The legislation, designed to help Americans who already have insurance, also would guarantee patients more information about their health plans' rules and benefits, forbid HMOs from "gagging" doctors who want to mention expensive treatment alternatives and compel plans to pay sometimes for a wider range of drugs.

After the House vote, Senate Assistant Majority Leader Don Nickles (R-Okla.), who is likely to lead the Senate negotiators, said he would be "drawing a line" against the broader reforms approved yesterday. Reiterating the GOP argument that more litigation against HMOs would be counterproductive, Nickles said, "I will work very aggressively to make sure we don't pass a bill which increases costs or increases the number of uninsured."

Given the wide differences between the chambers' approaches, key House members sounded similarly skeptical of success. "You don't see too many crossbreeds between chihuahuas and great Danes walking around," said Rep. Bill Thomas (R-Calif.), who chairs the Ways and Means health subcommittee and led this week's fruitless effort by the GOP leadership to drum up support at the last minute for a more limited bill.

In any case, the conference could well extend into next year.

Conferees also will have to sort through legislation, adopted by the House on Wednesday, creating a variety of controversial tax breaks and other innovations that Republicans say would make insurance more affordable to individuals and small companies. The tax breaks also are contained in the Senate's HMO bill, but they are opposed by Democrats, including Clinton, who contend they would primarily help people who are healthy and affluent while making little dent in the ranks of the nation's 44 million people without medical coverage. Democrats have accused the GOP of tying patients' rights to those tax measures in an attempt to kill chances for reform.

Some Republicans said yesterday that the party might have spared itself a defeat if their leaders had come out sooner in favor of a bill crafted by Reps. Tom Coburn (R-Okla.) and John Shadegg (R-Ariz.). In most ways, their bill resembled the bipartisan legislation that prevailed, but it would have permitted lawsuits only under severely limited circumstances.

After wavering for weeks and months, the GOP leadership latched onto the Coburn-Shadegg bill only three days ago. The bill was defeated by a 45-vote margin yesterday, just moments after House Speaker J. Dennis Hastert (R-Ill.) took to the House floor and uttered his first public comments in support of it.

In his floor speech, Hastert praised the doomed bill as "a solid, balanced approach" that "gives patients the care they need when they need it."

But Norwood countered that it offered people too little ability to enforce their rights, saying, "The poor patient [has] to jump through so many hurdles before they can get to [court]. . . . It is time we ask the insurance industry to be responsible for its actions."

While the margin of support for the Norwood-Dingell bill proved wide, the White House was taking no chances. Yesterday, Clinton, Vice President Gore, Chief of Staff John D. Podesta and two Cabinet secretaries chipped in to place phone calls touting the Norwood-Dingell bill to a few dozen House members of both parties who appeared to be wavering.

Rep. Christopher Shays (R-Conn.) received two messages from Clinton and spoke with Health and Human Services Secretary Donna E. Shalala, whom he told that he had already decided to support the Coburn-Shadegg bill and then, if it failed, the bipartisan measure.

Among area lawmakers, Maryland Republicans Constance A. Morella and Wayne T. Gilchrest crossed party lines to vote for the Norwood-Dingell plan, as did Virginia Republicans Herbert H. Bateman, Thomas M. Davis III and Frank R. Wolf. Virginia Democrat Virgil H. Goode Jr. opposed it.

Yesterday's victory was particularly sweet for Norwood, who had been trying for five years to persuade his party's leaders to schedule a vote on patient-protection plans like the one that prevailed yesterday. "Well, ladies and gentlemen, we are now on top of Hamburger Hill," Norwood said at a jubilant, bipartisan news conference in the Capitol basement immediately after the late-afternoon vote.

HMO Bill Highlights

Key differences and similarities between managed-care bills approved yesterday by the House and in July by the Senate:

Who is covered

House: Covers all Americans with private health insurance.

Senate: Many provisions apply only to 48 million people who are in plans regulated by federal law. They include greater access to emergency rooms, specialists and medications.

Right to sue

House: Lifts federal ban on lawsuits by people in health plans that fall under federal regulation. Injured patients could sue in state or federal courts for unlimited damages.

Senate: No new rights to sue.

Obstetricians and gynecologists

House: Women can see them without approval but can't choose them as primary-care doctors.

Senate: Similar, but only applies to federally regulated plans.

Emergency room treatment

House: Requires payment for reasonable emergency room services without prior approval.

Senate: Similar, but applies only to federally regulated plans.

Tax changes

Both allow self-employed people to deduct the cost of health insurance and create a new deduction for long-term care. Both allow more medical savings accounts, which let people set aside money, tax-free, to pay for routine care if they buy a high-deductible insurance policy in case of an emergency.

Appeals

Both require health plans to allow patients to appeal denials to experts outside the plan.

SOURCE: Associated Press