Politics & policy

Insight into federal and state health care legislation & CMS regulation

Court Allows Suits Against Pa. HMOs Over Care Issues

A Pennsylvania appellate court unanimously ruled that HMOs do more than simply pay for services. They actually deliver health care, and thus can be sued for medical malpractice on the grounds of corporate negligence.

The decision overturned a lower court's dismissal in 1996 of a medical malpractice lawsuit filed by an enrollee of HealthAmerica Pennsylvania. The plaintiff delivered a son prematurely, and the baby died. The lawsuit charged that the plan was negligent in supervising care provided by telephone by a physician, and in care provided by nurses who failed to properly refer her for care of premature labor.

The case expands to HMOs the corporate negligence theory of liability which, since a 1991 court decision, had applied only to hospitals in the state. "In adopting the doctrine of corporate liability [in 1991], the court recognized 'the corporate hospital's role in the total health care of its patients,'" Judge Joan Orie Melvin wrote in her decision. "Likewise, we recognize the central role played by HMOs in the total health care of its subscribers."

While acknowledging that HMOs do not practice medicine, the judge wrote that "they do involve themselves daily in decisions affecting their subscribers' medical care," and those decisions "must pass the test of medical reasonableness."

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