HMO Liability for Injuries on Denials of Coverage

Have you been injured or lost a loved one due to a health maintenance organization ("HMO") delaying a test or referral to a specialist, or denying insurance coverage for a particular test? It's understandable to feel angry and want to sue the HMO for their part in the injury or death. But it's a lot more difficult than you might expect to successfully sue an HMO.

Many state courts have ruled that state laws don't apply to lawsuits against HMOs, because HMOs are a form of employee benefit plan covered under the federal Employment Retirement Income Security Act of 1974 ("ERISA"). If a particular claim is covered by ERISA, you can't sue the HMO under state law for the doctor's medical malpractice negligence. This means you can only bring a lawsuit in state court against the doctor, not the HMO.

At least eight states - Arizona, California, Georgia, Maine, Oklahoma, Texas, Washington and West Virginia - now have laws that allow you to sue HMOs in medical malpractice cases. Some state laws hold health plans liable for patient harm when they have failed to exercise what's called "ordinary care" in making treatment decisions, making HMO plans liable for harm caused by treatment decisions made by employees, agents or representatives over whom they had influence or control. And in some states, HMOs can't drop a doctor from its panels or refuse to renew a doctor's contract because he or she stuck up for a patient.

If you're lucky enough to live in one of the states that allows lawsuits against HMOs, you may be able to sue for malpractice if you can show that your HMO or insurance company:

• Denied medical care that you needed or delayed approving medical tests or other treatment
• And the delay or denial caused you injury

In states that allow lawsuits against HMOs, you may be able to recover the cost of additional medical treatment, lost wages (current and future) and the pain and suffering you endured and continue to have as a result of your injuries. In some states, you may also be able to recover what's called "punitive damages," designed to punish the HMO or insurance company for outrageous practices.

If you believe an HMO or insurance company has injured you or a loved one, it's best to consult with an attorney right away, as there are often short time limitations on when you can bring a lawsuit. Once those time deadlines have run, you won't be able to sue the HMO.

Related Web Link:

Managed Care Abuse and Insurance Company Wrongful Conduct

Helpful HMO Liability Links:

Health Administration Responsibility Project

Legal Theories of HMO Liability:

Piercing the Armour: Approaches to Managed Care Liability
Health Administration Responsibility Project Tort Theories of HMO liability

Insurance Claims Message Board for more help