Health Maintenance Organization: Court Upholds Patient's Right To Sue For Negligent Assessment And Failure To Take Timely Action
Legal Eagle Eye Newsletter for the Nursing Profession
September 1999
Quick Summary: Claims of negligent care are not pre-empted by ERISA. The health maintenance organization doctor was a direct provider of healthcare services. He violated the standard of care owed to his patient by improperly assessing his condition and by failing to take reasonable steps to provide for timely treatment by a specialist.
The patient’s widow has the right to sue. COURT OF APPEALS OF NEW YORK, 1999.
A physician waited around for the patient to obtain his HMO membership card, then took his time sending out correspondence regarding the patient’s request to see his former physician who was a non-participant in the HMO.
According to the Court of Appeals of New York, he should have heeded the patient’s complaints of chest pain and sent him to a participating cardiologist no later than the next day.
The court cautioned healthcare professionals not to get too comfortable with the principle that patients cannot sue their HMOs. That principle applies only to management-level administrative and benefit-allocation decisions.
Negligent assessment and negligent failure to make use of available resources are medical care decisions, for which a patient can sue. Nealy v. HMO, 689 N.Y.S.2d 406 (N.Y. App., 1999).