When you see a doctor or go to the hospital, you expect to receive proper care for your condition. You certainly do not expect to have a medical professional worsen your condition or cause preventable complications.
Unfortunately, when professionals engage in medical negligence, patients can walk away in much worse condition and needing additional costly treatment.
People in this situation often file medical malpractice claims to seek compensation for their losses. However, when the malpractice happens by a managed care provider under ERISA, the law can seriously complicate matters and your rights.
Individuals seeking to navigate this complex legal terrain and pursue appropriate remedies for medical negligence need experienced legal counsel from a lawyer who focuses on ERISA claims. Medical malpractice lawyers with good cases that might get preempted should seek a referral from a skilled life insurance claims attorney to learn how to get their clients the best possible compensation.
ERISA and Medical Malpractice
Significant debate and litigation have involved ERISA (Employee Retirement Income Security Act) preemption of medical negligence claims against managed care providers. To understand this topic, we need to explore the principles of ERISA, the concept of preemption, and how they intersect with medical negligence claims against managed care providers.
ERISA is a federal law enacted in 1974 to establish standards and protections for employee benefit plans offered by employers. These plans can include health insurance, retirement benefits, disability benefits, and more. ERISA sets forth rules and regulations for the administration, funding, disclosure, and management of these plans.
One of the key features of ERISA is its preemption provision. ERISA Section 514(a) states that ERISA “shall supersede any and all State laws insofar as they may now or hereafter relate to any employee benefit plan.”
This preemption clause has far-reaching implications, as it means that if a state law “relates to” an ERISA plan, it is generally preempted and cannot regulate or enforce claims related to that plan.
Managed Care and Medical Negligence Claims
Managed care providers, such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs), often play a significant role in administering healthcare services to individuals covered by ERISA-governed health plans.
In some cases, disputes arise when individuals receive substandard medical care or medical negligence harm them within the managed care network.
ERISA Preemption and Medical Negligence Claims
ERISA preemption in the context of medical negligence claims against managed care providers revolves around whether these claims relate to an ERISA plan. If a court determines that a medical negligence claim relates to an ERISA plan, ERISA may preempt them, and the claimant may not pursue remedies through state courts.
Supreme Court Rulings
The U.S. Supreme Court has issued several key decisions addressing ERISA preemption. In the case of Aetna Health Inc. v. Davila (2004), the Court held that ERISA preempted medical malpractice claims against HMOs because the claims involved the denial of benefits, a matter that ERISA regulates.
Saving Clause and Insurance Exception
ERISA contains a saving clause (ERISA Section 514(b)(2)(A)), which preserves state insurance laws. However, the saving clause also includes an insurance exception, preempting state laws that regulate insurance if they “are inconsistent with the provisions of this subchapter” (referring to ERISA). This has led to further legal disputes about the scope of preemption.
Courts have grappled with the distinction between claims that challenge the denial of benefits (preempted) and claims that challenge the quality of care provided by managed care providers (not preempted). The nature of the claim and its framing can be crucial in determining whether it falls within ERISA’s preemption scope.
Potential Types of Medical Negligence by Managed Care Providers
Medical negligence by managed care providers can take various forms, as these entities play a significant role in overseeing and coordinating healthcare services for patients. While managed care providers aim to control costs and improve the quality of care, lapses in patient safety and treatment can occur.
Some potential medical negligence by managed care providers include the following:
- Delayed or denied treatment – Managed care providers may delay or deny necessary medical treatment or procedures to control costs. Such delays can result in worsened medical conditions and harm to patients, especially when time-sensitive interventions are needed.
- Failure to provide referrals – In some cases, managed care providers may fail to refer patients to specialists or other healthcare professionals when their conditions require specialized care. This can lead to misdiagnosis or inadequate treatment.
- Inadequate provider networks – Managed care providers are responsible for establishing networks of healthcare providers. Patients may receive substandard care if they include healthcare professionals who lack proper credentials or have a history of medical malpractice.
- Failure to monitor quality of care – Managed care organizations are responsible for monitoring and ensuring network providers provide quality care. Neglecting this duty can result in patients receiving care that falls below accepted medical standards.
- Miscommunication or lack of coordination – Poor communication and coordination among healthcare providers within a managed care network can lead to medical errors, including medication mix-ups, duplicate tests, and contradictory treatment plans.
- Inadequate patient education – Managed care providers are responsible for educating patients about their healthcare options and treatment plans. Failing to provide adequate information can result in patients making uninformed decisions about their care.
- Arbitrary utilization review decisions – Managed care providers often conduct utilization reviews to determine the necessity of medical procedures and treatments. Patients may suffer harm if these decisions are made arbitrarily or without proper medical justification.
- Overemphasis on cost control – While cost control is a legitimate goal, managed care providers must not prioritize it to the detriment of patient care. Overemphasis on cost-cutting measures can lead to reduced quality of care, inadequate staffing, and other unsafe practices.
- Incorrect billing practices – Patients may experience financial harm due to incorrect billing practices, such as being billed for services that should be covered by their insurance or receiving inflated bills.
- Inadequate credentialing and monitoring of providers – Managed care organizations must credential and monitor the healthcare providers within their networks. Failing to conduct thorough background checks or to address providers’ performance issues can result in patient harm.
- Neglecting patient safety protocols – Failure to adhere to patient safety protocols, such as proper sanitation, infection control, and medication administration, can lead to medical errors and patient harm.
- Inadequate management of chronic conditions – Managed care providers are often responsible for managing chronic conditions over time. Neglecting to provide adequate care for chronic illnesses can lead to complications and patient harm.
- Inadequate record-keeping – Accurate medical records are essential for patient care. Poor record-keeping by managed care providers can result in misdiagnoses, medication errors, and inappropriate treatment.
- Inadequate utilization of preventive care – Managed care providers should encourage and facilitate preventive care measures such as vaccinations and screenings. Failing to do so can result in preventable diseases or conditions.
- Conflicts of interest – In some cases, managed care providers may have financial incentives to limit treatment or referrals. These conflicts of interest can compromise patient care.
Patients who believe they have experienced medical negligence by managed care providers should seek legal counsel to explore their options for pursuing compensation and holding the responsible parties accountable.
Medical negligence cases often involve complex legal and medical issues, including ERISA complications, so consult with experienced attorneys who understand ERISA to navigate these challenges effectively.
How a Lawyer Can Help if ERISA Affects Your Rights to File a Medical Malpractice Claim against a Managed Care Provider
If a managed care provider injured you through medical malpractice, but the Employee Retirement Income Security Act may affect your rights, seek legal representation. Navigating the complexities of ERISA and medical malpractice claims requires specific knowledge and experience. Here are some ways an ERISA attorney can help in this situation.
Assessing the Viability of Your Claim
An experienced attorney will carefully evaluate your case to determine if medical malpractice occurred. They will review your medical records, consult experts if necessary, and assess the strength of your claim.
Understanding ERISA’s Impact
ERISA can affect your ability to pursue a medical malpractice claim, particularly if your healthcare coverage is through an employer-sponsored ERISA plan. Your attorney will examine your insurance policy, plan documents, and any potential preemption issues.
Identifying Liable Parties
Your attorney will identify all potentially liable parties, including the managed care provider, healthcare professionals, and the healthcare facility. They will also assess whether ERISA affects your ability to sue these parties.
Filing a Complaint
If your attorney determines that you have a valid medical malpractice claim, they will file a complaint in the appropriate court. They will properly draft and file the complaint within the statute of limitations, which varies by state.
Addressing ERISA Preemption
If ERISA preemption may affect your case, your attorney will develop legal arguments to minimize its impact. This may involve demonstrating that your claim does not relate to the ERISA plan or falls within ERISA’s insurance exception.
Engaging in Negotiations
Many medical malpractice cases resolve through negotiations or settlements before going to trial. Your attorney will negotiate on your behalf with the insurance company, managed care provider, or other parties to seek a fair settlement that compensates you for your injuries.
Your attorney will proceed with litigation if you cannot reach a fair settlement. They will prepare your case for trial, gather evidence, depose witnesses, and present your case in court.
Overcoming ERISA Challenges
If ERISA preemption becomes a significant issue, your attorney will use their legal experience to argue against it. This may involve demonstrating that your claim involves medical negligence, not an ERISA benefit dispute.
Proving Medical Negligence
Your attorney will work with medical experts to establish that medical negligence occurred. They will present evidence showing that the managed care provider or healthcare professionals deviated from the standard of care, resulting in your injuries.
Your attorney will also demonstrate the damages you suffered due to the medical malpractice, which may include medical expenses, pain and suffering, lost income, and other losses.
Your attorney’s goal is to maximize your compensation for your injuries and losses. They will use their legal knowledge and negotiation skills to seek the best possible outcome.
Your attorney will protect your rights throughout the legal process and ensure you receive fair treatment. They will navigate complex ERISA legal procedures, meet deadlines, and advocate vigorously on your behalf.
Dealing with medical malpractice claims can be stressful, especially when ERISA is involved. Having an attorney by your side provides peace of mind, knowing you have a legal advocate fighting for your rights.
Speak with an ERISA Lawyer Today About Your Possible Options
Navigating the intersection of ERISA and medical malpractice claims presents many legal challenges, and the legal landscape can vary from state to state.
Working with an experienced ERISA attorney can ensure that someone protects your rights and will pursue your case diligently, even in the face of potential ERISA-related obstacles. An attorney experienced in ERISA cases can provide the guidance and representation you need to seek justice and compensation for your injuries.
Following graduation from Loyola Law School in New Orleans in 1990, Price McNamara served as a Federal Judicial Law Clerk to the Honorable John M Shaw, Chief Judge, United States District Court Western District of Louisiana.
Mr. McNamara founded J. Price McNamara ERISA Insurance Claim Attorney, and began putting his past experience to work for the injured and disabled clients he now represents against the insurance companies in personal injury and long term disability and other insurance disputes in both federal and state courts