HMO/Managed Care and Medical Malpractice

Health Maintenance Organizations (HMOs) and other types of managed healthcare plans were established to help patients save money on their medical costs and avoid unnecessary expenses.

2012-11-02

DALLAS, TX, November 02, 2012 (Press-News.org) Health Maintenance Organizations (HMOs) and other types of managed healthcare plans were established to help patients save money on their medical costs and avoid unnecessary expenses. Unfortunately, because of efforts to stay cost-effective, the plans' quality of care often suffers. If an HMO refuses coverage to a patient when it was obligated to provide it, or if a patient is injured because of a negligent HMO doctor, this is grounds to pursue a medical malpractice case.

Negligence in HMO / Managed Care
HMOs are prone to medical negligence far too often. There are two main types of medical negligence that occur with managed care plans:

- Direct negligence - If an HMO doctor or staff member causes injury to a patient through a medical error, that patient can hold the HMO accountable for medical negligence. If an HMO forces a single doctor or office to take on too many patients, this can also be considered a form of direct negligence.
- Denial of coverage - If an HMO fails to provide obligated coverage for essential medical needs, and a patient suffers injury as a result, it is considered medical negligence. (Denial of coverage is also known as "bad faith insurance.")

Examples of direct medical negligence include:
- Misdiagnosis or delayed diagnosis
- Surgical errors
- Birth injury
- Emergency room negligence
- Prescription errors
- Anesthesia errors

The main reason why medical malpractice commonly occurs so often with HMOs is because so many major medical decisions are not made by doctors. Instead, HMO representatives dictate which health needs are covered, and which services will not be paid. When a doctor has to defer treatment decisions to someone who is not a health professional, the patient is always the one who suffers.

ERISA (Federal Employee Retirement Income Security Act)
ERISA is a federal law that was established to protect people from major health insurance companies. However, only a small part of this law enables individuals to file a complaint against their managed care organization. Another minor section states that ERISA nullifies medical malpractice laws within the state. This means that certain courts may decide that your ERISA right to file a complaint against your HMO voids state medical malpractice laws, which would prevent you from directly suing your HMO. However, ERISA does not apply to federal, state, and local government employees; these patients can file a grievance directly against their HMO.

Managed care laws are complex. If you have suffered injury or illness because of a negligent HMO, an experienced medical malpractice attorney can help you navigate the legal technicalities of your situation, carving a path for you to pursue the justice and compensation you deserve.

If you would like more information about HMO and managed care malpractice, please visit the website of the experienced Dallas medical malpractice attorneys at Polewski & Associates today at www.polewskilaw.com.

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