Texas jury finds HMO negligent in wrongful death case

Rather than alleging denial of care, these plaintiffs argued the insurer did not manage the patient's care the way it promised in its member handbook.

By Mike Norbut, AMNews staff. Aug. 15, 2005.

In a case that could have ramifications for the way courts view an HMO's role in patient care, a Texas jury last month found a local health plan negligent in a $7.4 million wrongful death case.

The jury in Bexar County District Court, which includes San Antonio, found Humana Health Plan of Texas responsible for 35% of those damages in Joan Smelik's death.

The Spring Branch, Texas, woman died in 2001 after complications of renal failure. Smelik's husband and two children sued, alleging that the HMO's failure to live up to its obligations of case management as described in its member handbook played a role in her death.

How the verdict could affect physicians in the future is still unclear. Some experts say the threat of a patient lawsuit against a health plan will give doctors a better chance to take HMOs to task for their decisions.

"I think doctors should get back in the business of knowing and challenging what HMOs are doing," said Brant Mittler, MD, a cardiologist in San Antonio and one of the Smeliks' attorneys. "They shouldn't just accept that they're not doing what they say they will."

But others say the verdict could blur the roles of physician and insurer and lead to second-guessing of a doctor's clinical decisions.

"To suggest an HMO or insurer has a duty to establish or maintain treatment protocols, I just don't know of other courts that have recognized that," said Barry Senterfitt, an Austin, Texas-based attorney who specializes in insurance law. "I don't think the insurance companies or physician community want that either. They already complain about medical necessity. Now this goes one step further."