HMO liability refers to holding a health maintenance organization or managed care organization responsible for failing to provide its patients with adequate health care. Examples of HMO malpractice include:

  • Delay or denial or tests
  • Delay or denial of treatment
  • Delay or denial of referral to a specialist

When Can an HMO Be Held Liable for Malpractice?

The laws regarding when an HMO can be liable for malpractice vary from state to state. While some states hold HMOs liable when they commit malpractice, other states tend to say that the Employee Retirement Income Security Act (ERISA) prevents patients from suing an HMO for malpractice.  In many states, most HMO corporate entities such as Kaiser cannot have medical malpractice claims brought against them, but rather must go through a mandatory arbitration process first because of a mandatory arbitration clause that is present in most contracts between HMOs and their clients.

What Is Arbitration for Medical Malpractice Cases?

Medical malpractice arbitration is a type of private legal procedure that does not go through the judicial system and is not governed by the courts. Since they are not governed by the judicial system, the state law does not apply and the contract made between the patient and the health care provider controls the entire procedure. Many HMO corporate entities that have private contracts with their patients would determine how the arbitration would proceed.

An arbitration process is similar to lawsuits. After the plaintiff has filed a arbitration claim against the defendant, the defendant can respond to the claim and the arbitrators would schedule a case management conference for pretrial investigation. Each side will then begin their discovery process by gathering written questions, requesting documents, taking depositions, and engaging in other aspects of the discovery process. After the discovery process is completed, an arbitration hearing will be set up and the parties will share the information with another and come up with an agreed settlement.

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

If your HMO committed malpractice that caused you injury, you can sue to recover damages including:

  • Cost of additional treatment
  • Lost wages / income
  • Loss of future earnings or potential income
  • Pain and suffering
  • Loss of companionship (for spouses)
  • Punitive damages

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

Injuries resulting from HMO malpractice can have a devastating effect on your life. If you have been injured in the course of receiving treatment from your HMO, a liability lawyer can help you recover damages for your injuries.