HMO Misconduct

What are HMOs?

HMOs or Health Maintenance Organizations are a large part of the American health care system. There are 482 distinct HMOs in the United States, and Illinois alone has 59 separate HMOs. An HMO is a type of group health insurance that requires its members to seek services with participating hospitals and physicians. What typically happens with an HMO is you get to “pick” a primary care physician (though this initial choice is often itself limited by the language of the HMO plan). If you need a medical specialist, you must often first go through your primary care physician, and then they will refer you to another doctor that is in network. Insurance companies claim that this reduces healthcare costs and reduces paperwork. However, people’s health and economics are not things that are always directly correlated, and healthcare organizations desire to keep costs down often negatively impacts patient care.

How does malpractice arise with HMOs?

Often, HMO members do not have a choice in who is providing their care and they must demand crucial tests and treatments. As HMOs work to keep costs down, patient care may be compromised. HMOs often offer incentives for physicians to keep costs down, resulting in the failure to perform critical treatments because they are costly. Actions for malpractice against HMOs can arise when the HMO delays or denies critical tests, delays or denies particular treatment, or delays or denies referring someone who needs care to a specialist. In addition to delay other potential causes of action may arise if your treatment ended sooner than it should have or if you only received partial treatment.

In some states, HMOs cannot be held liable because of a held liable because of a federal law called the Employee Retirement Income Security Act. This law preempts some state regulations. In Illinois however, HMOs can be liable for medical practice for delay or failure for treatment or other types of misconduct. Although Illinois law allows HMOs to be held liable for misconduct and be sued for malpractice, HMOs may include mandatory arbitration provisions in the contracts they have members sign, which adds a difficult legal challenge that should only be faced with the help of an experienced lawyer.

How can a lawyer help?

Of course, people who are healthy under their HMO plans rarely have reason to criticize or sue their health care provider. However, it is often the people who need the most health care, or who are the sickest who get mistreated by HMOs because their health care costs are so much more expensive

Medical malpractice lawsuits arise when physicians delay or fail to deliver proper care because of restrictions from HMOs. Our Chicago medical malpractice lawyers are experienced at handling cases involving HMO misconduct. In one case, our attorneys achieved a $7.6 million verdict against an HMO for failing to diagnose our 32–year–old client's abnormal bleeding after the birth of her daughter.

If you have experienced an incident of medical malpractice that is a result of HMO misconduct, please contact our offices to discuss your case with one of our veteran injury lawyers. For a FREE consultation, contact us online or call us at 877-374-1417 or 312–332–2872.