HMO Liability
The term “health maintenance organization” (HMO)
has been used in a variety of way and has limited use as a descriptive term. The
term can refer to almost any arrangement by which a corporate entity provides
healthcare services and often is used interchangeably with any managed care
enterprise. Patients can receive treatment at an HMO facility. This also
referred to as a “closed model HMO” or “staff model HMO”. In such instances, the
HMO serves as both a precertifier of care and as the employer of the physicians
who actually provided the treatment. Direct liability claims against HMO’s
almost uniformly are the result of the company employing utilization review to
deny care recommended by the patients’ physicians, resulting in the injury or
death of a patient. Utilizations review determinations are based on an
investigation into:
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Whether the treatment is part of the patient’s policy
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Whether it falls under one of the exclusions such as for investigational or
experimental treatment.
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Whether the treatment is “medically necessary”. Should the company decide that
the treatment is “medically necessary”, most policies allow the entity to then
select the most cost- efficient treatment available.
Cases illustrate that in circumstances, HMO’s can
be sued successfully for their conduct in denying care. Plaintiff’s cases have
alleged negligent conduct in all aspects of these determinations. However, it’s
clear that there is a conceptual difference between:
-
Denial Based on what appears to be a purely administrative determination that
there is no coverage
- A
determination that the treatment is not medically necessary. Denial of the
claim on the latter grounds requires the expert knowledge of a physician, or at
least some health care professional. Furthermore, there also may be a
distinction between a utilization review determination made prior to the
beginning of treatment, and one directing that ongoing care be altered in some
manner, delivered by another provided, or ended because it is no longer
medically necessary.
What is HMO negligence?
When an HMO member suffers an injury because the
HMO delayed or refused medical treatment, the HMO can be sued for HMO
negligence. In its broadest sense, HMO negligence is a type of medical
malpractice that can be defined as the carelessness of an HMO, acting through
its physicians, in making treatment decisions for a member that results in harm
to that member. Examples include:
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Failure to use diagnostic testing
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Failure to seek consultations with physicians outside of the HMO network
concerning a standard of care, the experimental nature of a course of
treatment, the reasonableness of a certain treatment, or the emergency
character of a medical condition
-
Failure to make referrals to physicians and facilities outside of the HMO
network
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Delay in transferring or failure to transfer a member to a hospital capable and
competent of administering necessary health care
-
Delay in treating or failure to treat a medical emergency
Types of HMO law cases:
There are several types of cases that can be
brought against HMO’s including:
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Wrongful Death- HMO’s can be sued when a person dies as a result of the HMO
denying coverage for necessary medical procedures.
-
Bad Faith- HMO’s can be held liable for denial of valid claims.
-
Malpractice- an HMO may be held liable for medical malpractice by one of its
physicians.
The Neil Kalra law offices in Forest Hills
Queens, New York concentrate in personal injury cases. Our practice areas include car and
motor vehicle accidents, medical malpractice, nursing home negligence, abuse and
injuries, lead paint poisoning, slip and fall accidents, medical malpractice, construction accidents, HMO liability and other
areas.
Contact
the Law Offices of Personal Injury Attorney Neil Kalra (in Forest Hills, Queens, New York)
immediately if you feel you have been hurt by the fault of another. Call
(718) 897-2211. Remember, if you don’t know your
rights, then you have no rights.
