Can HMOs be legally responsible for negligent doctors?

HMO denial of treatmentDoctors aren’t the only ones who are guilty of medical malpractice at times. In fact, health maintenance organizations (also known as HMOs) like Kaiser Permanente, U.S. Healthcare, Prudential and others may be to blame for their part in a patient’s injury or death; however, suing an HMO is more difficult than suing a doctor or hospital.

Generally, HMOs are not liable for the negligent actions of a doctor within their network. However, they should be liable if their actions caused a patient harm. HMOs charge fixed monthly premiums and are able to do so by controlling costs. Some examples of cutting costs can include refusing authorizations for tests, procedures, and hospital admissions in certain situations. 

If these decisions cause a patient harm, an HMO will likely deny liability by saying they made a benefit decision and not a medical decision. Yet we all know that HMOs set the guidelines for treatment and have authority over the physicians in their network. Sadly, many patients have been injured by HMOs interfering with recommendations made by their doctors.

If an HMO refused to refer a patient to a specialist or refused a biopsy or other test or procedure and that caused a patient further harm, an HMO should be held accountable. But there have been debates about whether or not HMOs should be held responsible for making poor treatment decisions (i.e., when they deny treatment that causes a patient further injury). Even in these cases, HMOs will argue that they only administer benefits and they are not legally responsible. In turn, they are allowing their doctors to take all of the blame.

If an HMO has denied you medical care or has delayed approving tests and treatments and those denials or delays caused you or a family member harm, you should still speak with a medical malpractice attorney. You may be able to file a malpractice suit against the doctor and hospital involved and then sue the HMO for breach of faith and negligence or for substandard care. Please call our law firm for a free consultation with an attorney skilled in this area of law.