HMO is an acronym often used to refer to health maintenance organizations tasked with providing health coverage in exchange for premiums paid by a policyholder. In short, they are a form of health insurance. In California, HMOs are also called health care service plans, though their purpose is the same. HMOs operate by presenting policyholders with a network of approved medical providers. As long as policyholders utilize the providers listed, they are eligible for healthcare coverage. However, you may be required to meet your deductible or pay a percentage of the costs, depending on the service.

Unfortunately, this system doesn’t always work the way it’s supposed to, resulting in instances of HMO medical malpractice. When you are reliant upon an institution like an HMO to handle your costs, many requests for care must be approved by the said institution. Your HMO must make that decision solely based on whether or not the request appears to be for something that can be considered medically necessary. However, the truth of the matter is that sometimes the decision to approve or reject a request is made based on financial implications instead of with full regard for the patient’s health. If you suspect this has happened to you, it may be time to get a professional San Diego HMO malpractice attorney involved.

When made by higher-ups sitting in their offices, these decisions may seem of little consequence. In actuality, this means that procedures, tests, and referrals to out-of-network providers are necessary elements of a patient’s treatment may be denied, putting them at risk. There have been many instances where patients sustained injuries as a result of the decisions made by their HMOs. The question, can you sue an HMO, isn’t very clear. So what legal recourse, if any, do they have?

The History of HMOs in California Law

In September 1999, the current governor of California signed the Senate Bill 21, which enabled private citizens to hold their HMOs accountable by allowing them to file claims against them when they act in bad faith. This means that patients can, in fact, sue an HMO. That being said, these are not easy cases to pursue. A skilled San Diego HMO malpractice attorney from Kenneth M. Sigelman & Associates can help walk you through the process, provide you with legal guidance, and ensure you have the best chance possible of winning your case.

One of the biggest complications when HMOs are involved is determining how to allocate responsibility for the injury, as there are multiple parties involved in the provision of medical care. HMOs often argue that they are merely the providers of benefits and are not liable for the decisions and behavior of their policyholders and the medical providers within their network. Finding a way to prove otherwise can be a difficult task. In addition, sometimes HMOs take preventative steps that interfere with your ability to file a claim in the first place.

Do Most HMO Malpractice Cases Settle?

HMOs are often large organizations with vast resources. Comparatively speaking, settlements are often much more cost-effective than drawn-out court cases, which could result in unexpected results. As such, even though they are generally less likely to lose a claim, HMOs will often move to settle out of court when possible. It is extremely rare for such claims to go to trial.

Many HMOs further complicate the matter by including arbitration clauses in the contract. This means that as a policyholder, you may be required to go through the arbitration process with an internal arbitrator instead of filing a civil action against them.

When negotiating a settlement, the parties involved participate in arbitration sessions, which ultimately determine the amount of the settlement. When going through arbitration, it is critical to have legal guidance from an HMO lawyer that can ensure you receive the appropriate compensation. Depending on the injury sustained, there are various types of damages you can claim, including the additional medical expenses incurred in treating the injury, loss of income during recovery, and pain and suffering endured. In some cases, it may also be possible to demand punitive damages.

Is It Better to Settle or Go to Court?

Many may find it intimidating to go against an HMO in the first place, let alone face them in litigation. Given the resources they have at their disposal, HMOs often can afford powerful legal teams with a history of successfully navigating through HMO malpractice claims. As such, you might be wondering if it would be best to settle outside of court when possible.

While the specifics will vary, there are often good reasons for people to choose settling outside of court over litigation. It’s not impossible to effectively win a claim against your HMO, but it must be acknowledged that there is a greater risk of losing the case. Additionally, litigation is likely to be an extensive process, meaning that it would take a significant amount of time for you to receive compensation if you win.

That doesn’t mean that your litigation should never be pursued. There are several examples of gross malpractice committed by HMOs that were contested in court with great success. However, depending on the details of your situation, it may be more convenient to settle. Settling a case will allow you to wrap up the case and obtain compensation in a much shorter time frame, which can help ensure that you are well provided for while you recover from your injuries.

Are HMOs Bad?

There are some benefits to having an HMO. Because the plans are prepaid, your primary care physician can provide you with care without worrying whether you can cover the expenses. As such, it essentially makes healthcare more accessible in some respects. However, HMOs require you to go through that same primary care physician before seeing any specialists or dedicated professionals and require requests for approval to be submitted if further procedures, tests, or out-of-network referrals might be necessary. This is where things generally take a turn.

The less care HMOs authorize for their patients, the more money they make. This puts them in a situation where it may seem in their own best interest to reject patient requests to remain profitable, which ultimately puts those patients at risk.

Is an HMO Worth It?

HMOs are often designed to be extremely affordable, making them attractive choices to those who are seeking healthcare on a budget. However, it’s important to understand that the lower premiums come with strings attached. Given the structure of the HMO, participants are often very limited in terms of the care and treatment they can seek out. As mentioned above, there is significant motivation present to encourage HMOs to withhold service. This doesn’t mean that all HMOs will inherently act in bad faith against their policyholders, but it is a matter worthy of consideration.

A common alternative to HMOs is PPOs or Preferred Provider Organizations. These prioritize the concept of freedom of choice, allowing policyholders the ability to seek out care from healthcare professionals outside of their network. Because of this, they also do not require any referrals when patients decide to seek out those external providers. However, on average, policyholders pay higher premiums for this flexibility, and over time those costs add up. Also, any procedures or treatments conducted out-of-network often come with a higher cost.

Is an HMO Right for You?

Deciding whether or not an HMO is worth having will likely depend largely on your health needs. While no one can predict the future, your medical history and that of your family can give you some insight to help you make that choice. If you suspect that you will likely have to seek treatment from specialists on a somewhat regular basis, it might be worth paying the higher premiums for a PPO. Additionally, if you have the funds for it and prefer the flexibility, you can also opt for such a plan. However, if you have limited income and don’t foresee requiring much assistance from specialists, the more affordable HMO plans may seem more appealing.

Contact San Diego HMO Malpractice Attorney, Kenneth M. Sigelman & Associates

If you decide to go with an HMO or are already receiving services from an HMO, it’s important to be fully informed of all the options you have if something goes wrong. If you believe that an injury you’ve sustained is due to an act of negligence from your HMO, call our firm. It’s critical to consult a San Diego HMO malpractice attorney as soon as possible to start building your case and assessing your options. Evidence is key, but it can take extended periods of research to gather, compile, and analyze that evidence, so time is of the essence. We have the legal experience and professional reach to get the help you need.

At Kenneth M. Sigelman & Associates, we have extensive experience representing HMO malpractice claims and ensuring our clients receive the compensation they are due. To learn more about whether you have sufficient grounds to file a claim, contact us online or call (866) 244-9285 to schedule a free review of your situation.