Important development to note here: “Texas Jury Finds Humana HMO Liable in Wrongful Death Lawsuit.”
Another article on the development: “Others may copy Humana suit: Insurer held liable over patient’s care.” Excerpt:
A $4.6 million judgment against Humana in a Texas wrongful-death case could lead to more suits against employer-sponsored health plans over patients’ care, legal experts say.The jury found Humana didn’t live up to its promise to coordinate medical care for the woman, who died at 66 of kidney-failure complications.
Health-law experts say the case illustrates an opening left by a U.S. Supreme Court decision last year that shut the door on many damage suits against health insurers.
According to the article, a “key piece of evidence in the three-week trial was Smelik’s Humana member handbook, which said the insurer would identify cases of chronic disease and make treatment recommendations to the patient, family and doctor.”
More on the case here:
In the Supreme Court decision, which also was based on suits filed in Texas, the court ruled patients may not pursue claims against their HMOs in state court, and that for their claims to move forward, they must follow the 30-year-old Employee Retirement Income Security Act of 1974, or ERISA law, and pursue their cases in a federal court (BestWire, June 21, 2004).The patients suits were “preempted” by ERISA, the high court ruled, essentially taking insurers off the hook for large jury awards. Once in federal court, patients may only seek the value of the benefit the insurer denied them?thus sparing insurers the potential of paying out vast sums in punitive damages, which state court juries often hand out (BestWire, June 21, 2004).
But the Smelik family’s case wasn’t barred by ERISA, Powell explained, noting its significance.
The Smelik family didn’t allege that Humana denied benefits to Joan Smelik, he said. “It wasn’t that a claim for a kidney doctor was submitted and Humana denied it,” Powell said. Instead, “it was the HMO’s failure in managing her care. She didn’t get a case manager; she didn’t get a kidney doctor,” as Humana specified in its member handbook, he said.