As patients seek expanded legal rights against their health plans, the Illinois Supreme Court last month determined that HMOs can be held liable for institutional negligence involving patient care.
In a ruling issued May 18, the court found that Chicago HMO can be sued for negligence because it assigned too many patients to a doctor, preventing a mother from getting treatment for her seriously ill infant.
The ruling is believed to be the first of its kind in the country.
"We hold that Chicago HMO had a duty to its enrollees to refrain from assigning an excessive number of patients to (the doctor)," the court wrote. "Public policy would not be well served by allowing HMOs to assign an excessive number of patients to a primary care physician and then wash their hands of the matter."
The ruling means that the HMO had a duty to do something in the interest of its patients and failed to do so, says Barbara Mayers, a partner with Chicago-based law firm McDermott, Will & Emery.
In 1991, 3-month-old Shawndale Jones became ill, and her mother, Sheila Jones, called her Chicago HMO physician. Jones described her daughter's symptoms to an assistant, who told her to give the infant castor oil. Jones insisted on speaking with the physician. That evening, when the physician called, he repeated the instructions to give the infant castor oil for symptoms that included constipation, excessive crying and a temperature.
The next day, Jones took her daughter to the emergency room, where she was approved for admission and subsequently diagnosed with bacterial meningitis, secondary to an ear infection. As a result of the meningitis, Shawndale is permanently disabled.
In court testimony, the physician estimated he was the primary care physician for 3,000 Chicago HMO enrollees and 1,500 enrollees of other HMOs. Chicago HMO's records showed the doctor was the primary care provider of 4,527 of its enrollees. HMO officials said they generally followed HCFA's guidelines of no more than 3,500 patients per primary care physician. In its contract with the Department of Public Aid to provide Medicaid services, Chicago HMO agreed that there would be at least one full-time physician for every 1,200 enrollees and one pediatrician for each 2,000 enrollees under the age of 17.
"We can easily infer from this record that (the doctor's) failure to see Shawndale resulted from an inability to serve an overloaded patient population," the court wrote. "The record indicates that Chicago HMO was actively soliciting new members door-to-door around the same time that it lacked the physicians willing to serve those members."
Chicago HMO has been subsequently acquired by Minneapolis-based UnitedHealthcare. A United spokesman says that the ruling only "gives the case the opportunity to be heard in court. And that's it."
It was the second time in seven months that the Illinois Supreme Court has ruled that patients can sue their HMOs.
In October, the Illinois Court ruled that an HMO can be held vicariously liable for the medical malpractice of its independent-contract physicians under the doctrines of both apparent and implied authority.
The U.S. Supreme Court is expected to rule later this month or in July on a suit in which an Illinois woman sued her HMO after she was told to wait eight days for a diagnostic ultrasound and her appendix burst, causing peritonitis. The woman won $35,000 in compensatory damages but claims the HMO breached its fiduciary duty and violated provisions of the Employee Retirement Income Security Act. The 7th U.S. Circut Court of Appeals reinstated that claim, and the HMO appealed to the Supreme Court, which heard arguments in January.