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Medical Malpractice within Health Maintenance Organizations

California HMO Medical Malpractice Attorneys

Millions of people living throughout California participate in healthcare plans provided by the nation’s largest Health Maintenance Organization (HMO), Kaiser Permanente. HMO plans are quickly losing popularity in the face of expanding Preferred Provider Organization (PPO) insurance options. However, HMOs are a part of everyday life for many people living in the San Diego area.

While HMOs offer some flexibility when it comes to treatment options and rates for coverage, they generally do not offer the same freedom when it comes to handling malpractice. If you or a loved one experienced any type of medical harm that you believe occurred due to malpractice within an HMO treatment plan, it’s vital to speak with a San Diego HMO malpractice attorney as soon as possible.

HMO’s are covered by the Employment Retirement Income Security Act (ERISA), which means that they are covered by federal, not state, law. While ERISA also covers all employer-provided insurance plans, victims of medical malpractice can still sue HMOs for negligence, but the process is extremely challenging.

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What Is an Example of HMO Malpractice?

Because an HMO requires a primary care physician to diagnose all medical conditions and make the discretionary decision whether or not to send a patient to a specialist, the HMO can be held liable if the primary care physician failed to send a patient to a proper specialist, or the primary care physician lacks the resources, knowledge, or skill to treat a patient appropriately, leading to injuries.

There are many examples where an HMO can be held liable for medical malpractice, including when a patient is denied medications by their HMO, and take a different medication leading to injury, when a primary care physician fails to refer a patient to a specialist, when the primary care physician makes a misdiagnosis, or even when primary care physician fails to order diagnostic tests.

This is not an exhaustive list of all the possible ways HMO malpractice could occur. Ultimately, if you believe that you or a loved one suffered any type of medical harm during the course of treatment through your HMO, you must consult a San Diego HMO malpractice lawyer as soon as possible to determine your best available legal options.

Are HMO Malpractice Cases Hard to Win?

One of the most challenging aspects of HMO malpractice cases is the frequent presence of arbitration clauses in injured patients’ policy agreements. Most HMOs, especially large ones like Kaiser Permanente, require their policyholders to sign arbitration agreements as a condition of their coverage. These agreements mean the policyholder waives the right to file private civil action against the HMO and agrees to private arbitration proceedings with the HMO’s internal arbitrator.

It is easy to see how this type of situation creates a very one-sided dispute resolution system that hardly favors injured patients. Additionally, since HMOs fall under federal jurisdiction with ERISA, patients with malpractice claims cannot take them to federal court as medical malpractice is not a federal issue; ERISA violations can only hold HMOs accountable for refusing to provide a treatment that the policyholder can prove had a medical necessity to receive and the appropriate coverage to receive it.

HMO malpractice claims can easily become tied up for years. Injured patients are left with bills that accumulate interest as they remain unpaid. If patients pursue legal action, HMOs can hold their benefits indefinitely while they hemorrhage money on legal fees. Additionally, ERISA violation claims pertaining to necessary treatments that were denied typically only yield compensation for the cost of the denied treatment. For example, if a screening that would have cost $400 was denied, and the screening could have prevented a patient from dying from an advanced medical condition, an ERISA claim would potentially only yield the cost of the denied screening.

How Do You Win an HMO Malpractice Lawsuit?

It is only possible to sue an HMO in federal court for clear ERISA violations. However, you can still take legal action against an HMO-employed physician if they caused medical harm through negligence. Whether or not the HMO employing the physician absorbs any liability for the damage is another question. Your San Diego HMO malpractice attorney can help you determine the best approach to a difficult case against an HMO doctor.

Winning your HMO malpractice lawsuit comes down to you and your attorney’s ability to prove that the defendant failed to meet the appropriate standard of care the situation in question demanded. Medicine is inherently uncertain as a field, and the medical community agrees upon proper treatments for known symptoms and conditions. Physicians must adhere to these standards of care for every patient they treat, and they must exercise their professional duties with the utmost care.

Elements of Medical Malpractice

Your San Diego HMO malpractice lawyer will assess your medical records and the scope of your damages to help you determine whether your claim is likely to succeed. The first step is establishing the four elements of medical malpractice:

  1. A doctor-patient relationship must have existed between the victim and the defendant. A plaintiff cannot identify a defendant in a medical malpractice claim with whom they did not share such an agreement. The plaintiff must produce a record showing the defendant agreed to treat the patient and that the patient agreed to the defendant’s treatment. This establishes the defendant’s responsibility to uphold the appropriate standard of care for the patient.
  2. The patient’s condition demanded a certain standard of care. Your attorney will work with medical experts and conduct detailed research to determine whether the defendant met the standard of care for your situation.
  3. The defendant failed to meet the patient’s required standard of care. Identifying the breach of duty of care committed by the defendant is the crux of a medical malpractice claim. It is sometimes necessary to consult outside experts to determine that a defendant failed to act in a manner consistent with adhering to the appropriate standard of care for the situation.
  4. The patient suffered harm and damages as a result of this failure. Sometimes doctors make mistakes during treatment and fix them immediately, or a medical error may result in little to no harm to the patient. For a patient to succeed with a medical malpractice claim, they must prove they sustained damaged or actual harm due to the defendant’s failure to meet the standard of care.

One of the most difficult aspects of fighting a medical malpractice lawsuit is the fact that many plaintiffs are intimidated by large companies like HMOs with powerful in-house legal teams. However, if the evidence of medical malpractice is quite clear, the defendant’s counsel will likely seek to settle the matter as quickly as possible for their client. Settlement can allow a defendant to move past a malpractice claim as quickly as possible. This generally benefits the victim and can obtain compensation for their losses more quickly.

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Second Opinions and Expert Medical Witness Testimony in HMO Malpractice Claims

In any medical malpractice claim, it is typically necessary for the plaintiff and their attorney to consult with medical experts to determine whether an incident in question qualified as medical malpractice or if the defendant in question failed to meet the appropriate standard of care for the situation.

Expert witnesses often come into play in medical malpractice claims to illuminate the details of a patient’s claim or to weigh in on the propriety of a defendant’s actions. Expert witnesses sometimes act in a consulting capacity to provide an attorney with an understandable professional interpretation of a complex issue, or they may testify in open litigation if necessary. Your San Diego HMO malpractice attorney will let you know what to expect when it comes to the experts and other medical professionals who may come into play during your case.

Damages from a Successful HMO Malpractice Injury Lawsuit

Many injured patients under HMO coverage will need to endure difficult arbitration and private settlement negotiation with the HMO doctor responsible for causing their damages. It is rare for medical malpractice claims to go to trial unless the defendant vehemently defends their actions and provides evidence they operated within an acceptable standard of care.

An experienced San Diego HMO malpractice attorney can help their client prepare for difficult arbitration sessions and ensure their client receives fair compensation for their losses. Some of the possible damages an injured patient could secure from a successful HMO malpractice claim include:

  • The cost of additional medical expenses. If medical harm required the patient to undergo further restorative treatment, increased their recovery time, or caused a medical ailment or disability that necessitates ongoing treatment, compensation could be higher. The patient can claim all immediate and anticipated future medical expenses caused by the defendant’s actions.
  • Lost income. Severe medical injuries can force a victim to remain in recovery for weeks or even months. Income lost during this time qualifies as claimable damages, including lost earning potential if the victim is unable to return to work in the future due to their injury.
  • Pain and suffering. Non-economic damages like pain and suffering are unfortunately capped at $250,000 in California medical malpractice claims. These damages seek to compensate a plaintiff’s physical pain and emotional distress caused by the incident in question.
  • Punitive damages, also known as exemplary damages. These are paid alongside the victim’s other damages and exist to punish the defendant for criminal wrongdoing, intentional harm, or gross negligence.

These damages can easily amount to a substantial potential recovery for an injured patient, but only with the right legal counsel on their side.

Why Do I Need an Attorney for HMO Malpractice?

Navigating any type of legal claim without an attorney is a significant challenge but attempting to do so during an HMO malpractice claim is a very bad idea. Simply put, if you face HMO arbitration, it is very easy for the average person to be incredibly intimidated in the face of powerful, experienced arbitrators and HMO private counsel. It is not uncommon for injured patients who attempt to arbitrate HMO malpractice claims on their own to wind up with little to no compensation for their losses.

Hiring an experienced San Diego HMO malpractice attorney to assist you with your claim increases the chances of successfully securing the recovery you need to get your life back to normal. Your attorney will manage your legal affairs on your behalf so you can focus your attention on your recovery. The right San Diego HMO malpractice lawyer will swiftly and accurately assess your legal options and help you determine the best approach to maximizing your compensation.

What to Expect From a San Diego HMO Malpractice Lawyer

When you hire legal counsel to represent you in an HMO malpractice claim, verify that your chosen attorney has solid experience handling claims similar to your own. Before agreeing to representation, take advantage of a consultation offer to get a better idea of how an attorney will handle your HMO malpractice claim. It’s also a good idea to develop some specific questions that pertain to your case. Asking these during your initial consultation can help you gauge how likely the attorney thinks you are to win your case.

Good San Diego HMO malpractice lawyers should provide responsive communication as your case unfolds, keeping the client updated about their latest case proceedings and preparing them for depositions, cross-examination, and other phases of their case. An HMO malpractice lawyer’s first priority should be to maximize their client’s recovery through every available channel of compensation.

Find Your San Diego HMO Malpractice Lawyer Now

Time is a critical factor in any legal case, especially one as complex and demanding as an HMO malpractice lawsuit. The sooner you connect with a reliable legal team and begin working on your case, the better your chances are of securing compensation for your losses. The HMO arbitration system is much easier to handle with a reliable attorney on your side, and the team at Kenneth M. Sigelman & Associates is ready to represent your HMO malpractice claim.

If you suffered injuries as a result of an HMO’s negligence, you have the right to sue for compensation for medical bills, pain and suffering, lost wages, and in some cases, punitive damages. Ken Sigelman can help you exercise your legal right to compensation. Because Ken is both a physician and a lawyer, he understands the intricacies of medical malpractice cases better than almost anyone. Please contact medical malpractice attorney Ken Sigelman in San Diego, California to learn more about your rights as a victim of medical malpractice or personal injury.

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Meet Our Attorneys

Ken Sigelman J.D., M.D. and his fellow attorneys at Kenneth M. Sigelman and Associates are medical malpractice experts, and bring that knowledge to cases involving the Federal Tort Claims Act to help you get the compensation you need!





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