Managed Care Abuse

Health Management Organizations or Health Maintenance Organizations (HMO), are health insurance company "managed care" entities.

Health insurance managed care has control over health care decisions, including those made by physicians, hospitals, and other health care providers. Through their contractual agreements (insurance policy) with policyholders (beneficiaries), managed care companies control -- or "manage" -- when the policyholder/patient may see a doctor, types of treatment which will be paid for, etc.

Part of the problem with this approach, is that medical decisions are often being made by non-doctors.  And, in those cases in which an outside doctor is consulted, that outside doctor or medical group, has been retained hundreds, if not thousands, of times by the HMO or managed care company.  Accordingly, that consulting physician or medical group -- if it wants to continue receiving the consulting fees -- is under pressure to find in favor of the managed care company or HMO and deny treatment.  Quid pro quo, alive and well.

HMO Claim Denial

Uneducated and poorly trained, HMO “representatives” – who more often than not seem to be glorified telephone-based bureaucrats - dictate to patients and their doctors what health services are covered, and too often, which health services are not covered and which the HMO will not pay. Of course, the consequences of a doctor having to answer to a non-health professional insurance telemarketer, can be catastrophic to the patient who does not receive the critical health care he or she needs.

decisions – second-guessing doctors and patients – which result in permanent harm or death – are outrageous. The trillion-dollar insurance industry, which reports annual profits in the tens of billions every year (often larger than oil companies), has effectively distorted a federal law called ERISA to protect themselves from some lawsuits.

The Federal Employee Retirement Income Security Act (“ERISA”) 29 U.S.C. § 1001, is a federal law that was originally designed to protect people from big health insurance companies. Nowadays, however, a very small section of this enormous federal law provides that an individual merely has the right to file a grievance against his or her HMO, PPO, or managed care company.

Another small provision of the law says that ERISA preempts – or voids – more favorable State laws.  Some courts have put these two provisions together and concluded that an ERISA beneficiary's right to file a grievance against an HMO preempts state medical malpractice law and prevents an injured person from suing the HMO that hurt them.

Have you been injured or lost a loved one due to an HMO delaying a test or referral to a specialist, or denying insurance coverage for a particular procedure? Has the HMO’s poor decision-making resulted in catastrophic injury or death?

Successfully suing an HMO for its misconduct is a difficult path; however, in some circumstances it can be done. Contact us for a free consultation and we will evaluate your case and your rights under your circumstances.

Remember, ERISA does not apply to everyone. There are important exceptions and persons exempted from the ERISA scheme.  For example, employees of the federal government, State governments, and local governments (e.g. firefighters, police, public hospitals, teachers, and other government employees, etc.), are generally exempt from ERISA and can file a bad faith lawsuit against the HMO.

Who Can Be Held Accountable?

If a particular claim is covered by ERISA, then in many instances you cannot sue the HMO under State law for the HMO's denial of treatment decision or the doctor's medical malpractice. This means you can only bring a lawsuit in State court against the doctor, not the HMO.

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.

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 health insurance company has improperly denied your claim, refused to cover an important medical procedure or surgery, or otherwise injured you or a loved one, contact us -- now.

HMO claims denials, HMO malpractice, insurance managed care abuse, often result in harms to the consumer. Protect your rights, assert your rights, and fight the HMO bureaucrats. Contact our consumer injury attorneys today.

We're Here to Help - Throughout Florida and Beyond

For dedication and experience, contact our injury lawyers.  We proudly serve deserving clients and their families who are seeking to overcome the challenges of serious personal injury and wrongful death throughout Florida and the U.S.*

We provide aggressive, prompt, and ethical advocacy on behalf of individuals and families who have suffered serious personal injury and wrongful death as the result of hmo denial of care, managed care abuse, and health insurance denial of treatment. Contact us today.

* In cases outside Florida, we co-counsel or jointly prosecute the claim with local counsel.