HMO Negligence

HMO negligence is a civil lawsuit that falls under the broader category of medical malpractice. In this type of claim, a health maintenance organization (HMO), under which a patient has health insurance coverage, is named as a defendant in a medical malpractice personal injury case.

In HMO negligence cases, the HMO may be the sole defendant, but is more commonly named as a co-defendant along with a physician or other healthcare provider, facility, or entity.

HMOs select and contract with physicians and other healthcare providers. This contracted arrangement is what makes it possible, in some medical malpractice cases, to name the HMO as a defendant along with the healthcare provider.

Because the HMO encourages the use of the physician or other healthcare providers’ services, and in fact requires it’s beneficiaries to utilize the services of only in-network providers in order for healthcare insurance claims to be paid, the claimant in a personal injury lawsuit can argue that the HMO is at least partially responsible for any damages that result from the medical care received from one of its members.

The most successful HMO negligence lawsuits stem from arguments that assert:

  1. the HMO failed to properly screen it’s contracted members
  2. the HMO’s advertisements of only contracting with members who meet a particular “quality of care” standard or rating is inaccurate

In most HMO negligence lawsuits, the claimant pursues damages based on the concept of “breach of contract”, which essentially means the HMO failed to provide the promised services, agreed upon within the contractual relationship between the HMO as an insurance provider, and the beneficiary (claimant) as the insurance plan participant and payee of health insurance plan premiums.

In cases where an HMO’s own marketing materials make bolder statements about the physicians and other healthcare providers that participate in the organization, courts are more likely to find the defendant liable for damages. In some cases though, HMOs are protected from medical malpractice lawsuits, simply by virtue of their own “contract” language contained within insurance coverage enrollment documents and plan policies.