Law Offices of Neil Kalra, PC. Personal Injuries lawyer in Forest, Hills, Queens, New York

Home Page of Neil Kalra, personal injuries lawyer, Queeens, NY

Practice areas handled by Neil Kalra
Motor Vehicle Collisions: what to do
Burn Injuries
Construction Injuries
Fall Down Injuries: what to do if you have an accident

Nursing Home Abuse and Injuries: what to look for
Birth Related Injuries
Lead Paint Poisoning
HMO Liability
Contact the law offices of Neil Kalra, in Forest Hills, Queens, NY

HMO Liability

The term “health maintenance organization” (HMO) has been used in a variety of way and has limited use as a descriptive term. The term can refer to almost any arrangement by which a corporate entity provides healthcare services and often is used interchangeably with any managed care enterprise. Patients can receive treatment at an HMO facility. This also referred to as a “closed model HMO” or “staff model HMO”. In such instances, the HMO serves as both a precertifier of care and as the employer of the physicians who actually provided the treatment. Direct liability claims against HMO’s almost uniformly are the result of the company employing utilization review to deny care recommended by the patients’ physicians, resulting in the injury or death of a patient. Utilizations review determinations are based on an investigation into:

  • Whether the treatment is part of the patient’s policy
  • Whether it falls under one of the exclusions such as for investigational or experimental treatment.
  • Whether the treatment is “medically necessary”. Should the company decide that the treatment is “medically necessary”, most policies allow the entity to then select the most cost- efficient treatment available.

Cases illustrate that in circumstances, HMO’s can be sued successfully for their conduct in denying care. Plaintiff’s cases have alleged negligent conduct in all aspects of these determinations. However, it’s clear that there is a conceptual difference between:

  • Denial Based on what appears to be a purely administrative determination that there is no coverage
  • A determination that the treatment is not medically necessary. Denial of the claim on the latter grounds requires the expert knowledge of a physician, or at least some health care professional. Furthermore, there also may be a distinction between a utilization review determination made prior to the beginning of treatment, and one directing that ongoing care be altered in some manner, delivered by another provided, or ended because it is no longer medically necessary.

What is HMO negligence?

When an HMO member suffers an injury because the HMO delayed or refused medical treatment, the HMO can be sued for HMO negligence. In its broadest sense, HMO negligence is a type of medical malpractice that can be defined as the carelessness of an HMO, acting through its physicians, in making treatment decisions for a member that results in harm to that member. Examples include:

  • Failure to use diagnostic testing
  • Failure to seek consultations with physicians outside of the HMO network concerning a standard of care, the experimental nature of a course of treatment, the reasonableness of a certain treatment, or the emergency character of a medical condition
  • Failure to make referrals to physicians and facilities outside of the HMO network
  • Delay in transferring or failure to transfer a member to a hospital capable and competent of administering necessary health care
  • Delay in treating or failure to treat a medical emergency

Types of HMO law cases:

There are several types of cases that can be brought against HMO’s including:

  • Wrongful Death- HMO’s can be sued when a person dies as a result of the HMO denying coverage for necessary medical procedures.
  • Bad Faith- HMO’s can be held liable for denial of valid claims.
  • Malpractice- an HMO may be held liable for medical malpractice by one of its physicians.

The Neil Kalra law offices in Forest Hills Queens, New York concentrate in personal injury cases. Our practice areas include car and motor vehicle accidents, medical malpractice, nursing home negligence, abuse and injuries, lead paint poisoning, slip and fall accidents, medical malpractice, construction accidents, HMO liability and other areas.

Contact the Law Offices of Personal Injury Attorney Neil Kalra (in Forest Hills, Queens, New York) immediately if you feel you have been hurt by the fault of another. Call (718) 897-2211. Remember, if you don’t know your rights, then you have no rights.

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