California Supreme Court says patients can sue Medicare HMOs

Patient advocates hail the ruling as a needed step to assure accountability; others say it undermines congressional intent.

By Tanya Albert, AMNews staff. May 21, 2001.

California Medicare patients in HMOs can sue insurers in state court if their insurers deny necessary treatments, the California Supreme Court ruled earlier this month.

The 5-2 ruling gives California residents the same rights federal courts already have given senior citizens enrolled in Medicare health plans.

HMOs say the state supreme court's opinion will create havoc, leaving decisions in the hands of individual judges and juries applying different standards rather than based on a federal law with one standard.

Patient advocates, including the AARP, say the ruling gives patients the right to hold their HMOs accountable for decisions.

"Doctors should provide the care people need and try to withstand the pressure from HMOs to take financial considerations into account when deciding what is the best medical decision," said Los Alamitos, Calif., attorney Carol Jimenez, who represented the family suing the HMO.

The ruling allows Barbara McCall to go forward with a suit accusing PacifiCare of California Inc. of negligence, willful misconduct, four counts of fraud, and negligent and intentional infliction of emotional distress.

McCall's husband, George, was enrolled in PacifiCare and was suffering from a progressive lung disease. PacifiCare and its physicians "repeatedly refused" to refer him to a specialist for a lung transplant, according to court documents.

Ultimately, he was forced to opt out of the Medicare HMO and to enroll in traditional Medicare to get on the transplant list. McCall's condition worsened in the time it took to make the switch. He died shortly after receiving a transplant. [...]