Compliance July 5, 2001

Medicare HMO Patients Win California Victory

May 7, 2001 (PLANSPONSOR.com) - The California Supreme Court handed Medicare HMO beneficiaries a major victory last week, acknowledging the right to sue health maintenance organizations for damages in state court.

Reported by

Nevin E. Adams

The 5-2 decision further expands a growing trend toward greater health care provider accountability for medical decisions.

The ability to bring damage suits in federal or state court is a key element in the national debate over a patient’s bill of rights.

Case History

Before he died in 1999, George McCall sued HMO Pacificare of California and others, alleging that he was denied a lung transplant because it cost too much. The year prior to his death, a court ruled that the disabled and those 65 and older enrolled in a Medicare HMO could only pursue federal administrative claims to get services they alleged were withheld.

However, California’s high court now says that senior citizens and the disabled who sustain injuries because of a lack of care can sue in California courts.

For its part, Pacificare says it did not deny the transplant, but instead denied McCall his choice of hospitals, said Ben Singer, a company spokesman cited by Dow Jones.

According to Dow Jones, legal experts said the 1998 decision was the nation’s only such ruling.

Healthcare experts predict that an increase in such lawsuits could result in the state.