HMO Malpractice Liability

HMO stands for health maintenance organization. HMOs have their own network of physicians, hospitals, and other healthcare providers who have agreed to accept a particular payment amount for their services. This helps the HMO to keep its members’ expenses low.

What Can HMOs Be Liable For?

HMO liability refers to holding a health maintenance organization or managed care organization accountable for failing to provide proper health care to its patients.

Examples of HMO malpractice include:

• Delay or rejection in testing
• Treatment deferral or rejection
• Delayed or denied referral to a specialist

When Can an HMO Be Held Liable for Malpractice?

The rules regulating when an HMO might be responsible for malpractice differ from state to state.

While some jurisdictions hold HMOs accountable when they commit malpractice, other states prefer to assert that the Employee Retirement Income Security Act (ERISA) precludes consumers from suing an HMO for malpractice.

In many states, most HMO corporate organizations, such as Kaiser, cannot have medical malpractice claims made against them but must go through a mandated arbitration procedure.

Mandatory arbitration provisions are found in most contracts between HMOs and their customers.

What Are the Requirements to Sue an HMO?

It is difficult to sue an HMO.

ERISA enables an HMO to be covered by federal law, as opposed to state law, and hence can’t be sued by the state.

Some states enacted legislation to enable litigation against HMOs. Still, the United States Supreme Court decided in favor of the HMOs (against the states) to reaffirm that federal law would take precedence over state law. Any insurance plan supplied by an employer to workers is covered under ERISA, excluding insurance plans for government employees.

Nonetheless, a patient has the right to sue an HMO for withholding medical treatment or medicines. Most malpractice cases against an HMO are connected to rejections of treatment or failures of care by the primary care physician.

Are There Any Limitations on Suing HMOs?

The answer is “yes.” Suing your HMO is more difficult than suing a doctor or a hospital.

HMO liability refers to holding an HMO or managed care organization accountable for failing to provide proper health care to a patient. This failure resulted in the patient’s harm or perhaps death.

HMOs like Kaiser Permanente, US Healthcare, Prudential, and others may be held accountable for a patient’s harm or death. Some jurisdictions require HMOs to be responsible when they commit malpractice. In contrast, others restrict the compensation you may claim if your health insurance comes through your employers, such as pain and suffering or punitive penalties.

For example, the Kaiser Permanente organization includes a required arbitration provision in most of its HMO contracts that prevent medical malpractice cases from being launched against them.

Instead, a patient must first go through a required arbitration process, a private legal procedure that is not overseen by any court and does not go through the judicial system.

Therefore, the regulations of a specific state controlling HMO responsibility don’t apply. Rather, the procedure is governed by the contract between Kaiser and its patients.

Why Does it Seem that Your HMO is Refusing to Fund Your Treatment?

Consider the following:

You pay your insurance company a premium for auto insurance and hope you never have a car accident. But, sooner or later, everyone will have to submit a claim on their insurance coverage.

The vehicle insurance business earns a profit if it can pay out less than what they get in premiums. As a result, their motive is to settle your claim for the smallest amount feasible to boost the company’s bottom line.

Many individuals choose an HMO plan since it is less expensive. However, the HMO must pay everyone’s medical expenses from the budget funded by member (and employer) contributions.

To be sustainable, the HMO must spend less on treatment expenses than it receives in premiums. That is why the HMO constantly weighs risk vs. outcome when determining what medical treatment should be covered and to what degree.

What Are the Distinctions Between Medical Malpractice and HMO Malpractice?

Medical malpractice is the sort of personal injury case you’d bring if a healthcare provider’s carelessness caused you to get sick or injured. Under the conditions, the provider’s behavior must fall below the established standard of care.

Medical malpractice may involve (but is not limited to) the following:

1. Inability to diagnose (or incorrect diagnosis)
2. Important lab findings are misread or ignored.
3. Unnecessary surgery or other treatment
4. Surgical blunder
5. Improper medication or prescription
6. Insufficient follow-up care or instruction
7. Premature hospital discharge

An HMO is normally not accountable for the mistakes of an in-network doctor. However, if the HMO makes a choice that causes damage to the patient, it should be held accountable.

For example, if the HMO rejects permission for a test, treatment, or hospital admission and the patient suffers sickness or damage as a consequence, then they might be found at fault.

An HMO may argue that it is not responsible since it made a benefit choice rather than a medical decision. But, although that could be true, the HMO influences its network providers and establishes criteria for care.

What Is Arbitration for Medical Malpractice Cases?

Medical malpractice arbitration is a private legal proceeding that is not overseen by the courts and does not go through the judicial system.

The arbitration process would be determined by several HMO business organizations that have private contracts with their patients.

After the plaintiff has filed an arbitration claim against the defendant, the defendant might reply to the claim, and the arbitrators would arrange a case management session for pretrial inquiry.

Each party will then begin its discovery process by compiling written questions, seeking documents, taking depositions, and participating in other components of the discovery process.

Following the completion of the discovery process, an arbitration hearing will be scheduled, during which the parties will disclose information and reach an agreement.

What Damages Can I Recover If My HMO Is Held Liable?

There are damages available when suing a health insurance company. If your HMO caused you harm, you have the right to seek compensation, which may include the following:

• Additional treatment costs
• Lost wages/income
• Future profits or prospective income lost
• Pain and suffering
• Loss of companionship (for spouses)
• Punitive measures

Is an HMO Plan Appropriate for Me?

When deciding if an HMO plan is best for you and your family, there are various aspects to consider. Some crucial items to consider are:

• Cost of monthly premiums
• Out-of-pocket expenses
• Using a primary care physician vs. selecting your own healthcare providers
• The present state of health of the persons you want to insure

An HMO plan might save you money if you don’t need a lot of specialist care or don’t mind having your treatment managed via a PCP.

Do I Need a Lawyer to Sue an HMO for Malpractice?

Injuries caused by HMO malpractice may have a catastrophic impact on your life. A liability lawyer could assist you in recovering damages if you were hurt while seeking care from your HMO.

Don’t delay your claim any longer. A lawyer can help you recover the damages you are entitled to. Use LegalMatch to find a defective product lawyer today.