HMOs may lose malpractice immunity

The viability of a case brought by a patient's estate represents one more brick removed from the ERISA wall that had protected plans from liability.

By Tanya Albert, AMNews staff. March 10, 2003.

A federal court ruling that holds health plans accountable for decisions that are medical -- and not simply administrative coverage determinations -- bolsters the doctor-patient-relationship, physician groups say.

A three-judge panel of the 2nd U.S. Circuit Court of Appeals in February gave a widow the go-ahead to sue an HMO for medical malpractice in a state court. The New York woman's husband, Carmine Cicio, died after his insurer would only approve a less-aggressive cancer treatment than the one his physician recommended as the best course of treatment.

"The language in the decision recognizes that [health plans] have intruded on medical decision-making," said Donald R. Moy, general counsel for the Medical Society of the State of New York, which filed a friend-of-the-court brief along with the American Medical Association/State Medical Society Litigation Center. "It's a precedent-setting decision."

The ruling "is a step in the right direction for both physicians and patients," added Joel J. Ziegler, an attorney who represented Carmine Cicio's wife, Bonni.

The 2nd Circuit's ruling in Cicio v. Vytra Healthcare and Brent Spears, MD, directly applies to people in Connecticut, New York and Vermont. But legal experts believe other courts could apply the same logic in their jurisdictions if the ruling holds.

Vytra could appeal the decision to the U.S. Supreme Court. But company officials would not comment on their next move. "It is the company's policy not to discuss matters in litigation," said a spokeswoman.