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HMOs Can Be Sued for Malpractice if Treatment Is Denied

  Alan Fuchsberg  |  September 12, 2016  |  

If you have suffered adverse effects from a Health Maintenance Organization (HMO) denying treatment or care, you can sue the HMO.  A court ruling issued in 2013 established the right of consumers to sue HMOs and their medical directors for medical malpractice. The ruling was issued by the United States Court of Appeals for the Second Circuit in New York.

Consumers Can Sue an HMO under New York Medical Malpractice Law

In previous years, claims of medical malpractice by an HMO were often rejected. David L. Trueman, a lawyer who filed the suit that led to the 2013 court decision, said “This ruling means that there’s now no barrier for anyone in New York… to sue an HMO when the health plan denies treatment recommended by a doctor. Millions of consumers have a right they did not have before.”

One of many cases that ushered in this court decision was from 1998, involving Carmine Cicio from Suffolk County, New York. Carmine had a rare form of blood cancer known as multiple myeloma. His oncologist wrote a letter to Vytra Healthcare, looking for approval to treat Mr. Cicio with a high-dose of chemotherapy and stem cell infusion that Mr. Cicio’s doctor said was a “well-established method of treatment.” According to him, this treatment increased Mr. Cicio’s chance of survival compared to other forms of therapy.

But Dr. Brent Spears, Vytra’s medical director, denied the request, claiming the treatment was risky and experimental in nature. Because of this, insurance wouldn’t cover it. Mr. Cicio’s doctor appealed this decision and after a couple of months, the company finally approved a different chemotherapy treatment, one that was considered by doctors to be less effective.

In May that year, Carmine Cicero succumbed to his ailment and passed away. His late wife, Bonnie Cicio, sued Vytra Healthcare and Dr. Spears, claiming that if the HMO had approved the initial treatment, her husband might still be alive. But the court rejected her appeal, saying that an appropriate medical decision and another suggested treatment was made to help Mr. Cicio.

The Employee Retirement Income Security Act (ERISA)

At the time, Vytra was protected by the Employee Retirement Income Security Act (ERISA), which acted as a major barrier for Mr. Cicio’s widow to receive any damages from pain and suffering and lost wages due to the death of her husband. ERISA bars states from enforcing laws that would allow HMO members to sue them for the negligent failure to authorize treatment. In this specific case, ERISA provided very limited benefits to Mrs. Cicio.

Effect of the Affordable Care Act

When the Affordable Care Act (ACA), familiarly referred to as ObamaCare, was established in 2010, a giant shift in the healthcare market occurred in an attempt at reformation. Despite its positive intentions, the new health law affected millions of people in New York and across the nation who received health care through their insurance plans. Many moved on to HMOs, with restrictive covenants regarding resolving disputes about health care.

Though HMO’s are relatively low in cost, their limitations are stifling, especially if a person needs to seek treatment outside if their HMO network. These insurance plans are under a lot of public scrutinies and have a poor reputation due to the ethics behind what they’ll do to hold down medical costs, such as denying life-saving but potentially expensive treatment. Such was the case with Mr. Cicio, who suffered the worst consequences of the HMO’s refusal to administer the best treatment for his disease.

If You Have Been Denied Treatment by an HMO

If you have been denied treatment by an HMO, or if your loved one has suffered because of an HMO decision, our New York medical malpractice lawyers may be able to help.  Contact us today.

Sources:
“http://www.nytimes.com/2003/02/18/us/a-court-expands-the-rights-of-patients-to-sue-hmo-s.html?”
“http://nypost.com/2015/10/14/obamacare-just-killed-my-health-insurance-again/”
“http://obamacarefacts.com/health-plan-types-hmo-ppo/”
“http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449155/”
“http://www.cnbc.com/2015/10/29/fewer-plans-to-be-on-biggest-obamacare-exchange-in-2016.html”

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