HMO Malpractice

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Health maintenance organizations (HMOs) are organizations that contract with physicians, hospitals, clinics and employers to provide healthcare to a group of individuals. With this type of insurance, the person’s employer pays for the majority of the premium.

HMOs must finance needed care from a limited budget supplied by member payments. For this reason, they are motivated to count costs, and balance risks versus results in deciding whom and what receive financial assistance for medical care.

Many Americans rely on the affordable nature of HMOs for getting the health care they need. Unfortunately, sometimes HMOs refuse to pay for necessary tests and procedures, fail to reimburse patients for treatments that should be covered, and or completely deny coverage to an eligible policyholder. Such instances of health care coverage denial might be considered HMO malpractice.

If you or a loved one was the victim of HMO malpractice, contact the experienced Boston medical malpractice lawyers at Bellotti Law Group, P.C. today at 617-225-2100 for a FREE consultation to discuss your options.

HMO Negligence

HMO negligence refers to any action by an HMO that results in the injury or fatal death of an individual who pays for health coverage.

General Types Of HMO Malpractice

• Turning down eligible members without clear reasons
• Refusing to pay for various necessary treatments due to the high cost of the procedures
• Wrongful death: HMOs can be sued when a person dies as a result of the HMO denying necessary medical treatment —
  • Delay in approval of claims: since HMOs provide health care to their clients through a network of contracted health care professionals, the system sometimes results in a slow process for patients. For individuals who aggressive diseases, this delay may be fatal.
  • Delay in treatment: patients who need treatment for life-threatening conditions might find their medical assistance delayed due to high volumes of paperwork.
  • Denial of claim: many HMOs refuse life saving or preventative treatments because it does not meet the cost – reward formula many companies follow.
• HMOs can be held liable for denial of valid claims
• An HMO may be held liable for medical malpractice on the part of the nurses or acting physicians

Who is responsible?

• The actual HMO representative and or company
• Doctors: a physician may suggest that a patient undergo a specific or series of examinations that will lead to the doctor’s high compensation.
• Constituent hospitals
• A provider may be liable for failing to follow customary practice in making a diagnosis or choosing a type of treatment.

Bad Faith Lawsuit

When an individual enters into a contract with an HMO to receive health care, the HMO is obligated to do everything in their power to provide the necessary assistance for the patient in “good faith” of the agreement. If they attempt to refuse to honor a claim of a person who has entered into such a contract, the individual may be able to file a bad faith lawsuit.

Call the Boston medical malpractice attorneys at Bellotti Law Group, P.C. today at 617-225-2100 for a free consultation. Put our decades of experience and success to work for you.