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HMO/Managed Care and Medical Malpractice

HMOs (health maintenance organizations) and other managed care plans were originally created to help people save money on healthcare expenses and avoid unnecessary medical costs. Unfortunately, in an effort to be frugal and cost-effective, the quality of care that HMOs provide tends to be lower.

If an HMO denies coverage when it was obligated to provide it, or if you are injured because of an HMO doctor’s negligence, you can pursue justice and compensation through a medical malpractice case. A dedicated attorney at Colling Gilbert Wright can act on your behalf. For a free consultation, please call (407) 712-7300 today.

HMO/Managed Care Negligence

Medical negligence occurs all too often with Florida HMOs. The two most common types of negligence are as follows:

  • Coverage denial (bad faith insurance): When an HMO plan refuses to provide coverage for essential medical needs, patients can suffer injury or illness.
  • Direct negligence: If an HMO hires incompetent or inexperienced doctors and staff members who cause injury through medical errors, you can and should hold the HMO accountable for negligence. Direct negligence can also occur when an HMO burdens a single office or physician with too many patients.

Examples of Direct Negligence

Direct negligence involves common medical malpractice situations, such as:

Part of the problem with HMOs is that many important medical decisions are made by non-doctors – “representatives” who dictate which health services are covered, which are not, and which the HMO refuses to pay. When doctors have to answer to non-health professionals, the consequences can be catastrophic to the patient.

Understanding ERISA

ERISA stands for the Federal Employee Retirement Income Security Act, a federal law that was originally enacted to protect patients from large health insurance companies. Today, only a small section of this law states that individuals have the right to file a grievance against their HMO, PPO, or other managed care organization.

Another section says that ERISA pre-empts more favorable state medical malpractice laws. What does this mean? Unfortunately, it means that some courts may conclude that your ERISA right to file a grievance against your HMO voids the state’s medical malpractice laws, preventing you from directly suing the HMO that caused you injury.

However, ERISA does not apply to everyone. Federal, state, and local government employees are usually exempt from ERISA, allowing them to file a bad faith complaint against their negligent HMO.

The laws surrounding lawsuits against HMO providers are complex. Our experienced Florida medical malpractice attorneys can evaluate your case, determine your rights, and help you unravel best possible path forward.

If your HMO or managed care plan has caused you injury because of its negligence, please contact Colling Gilbert Wright online or on the phone at (407) 712-7300 today to schedule your free initial consultation. We represent injured medical malpractice victims throughout the Orlando, Florida area.

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