POTENTIAL
EXPOSURE FOR CREDENTIALING, QUALITY ASSURANCE, UTILIZATION MANAGEMENT AND MEDICAL
MALPRACTICE (CON'T)
Brock D. Phillips
Dr. Self obtained a verdict awarding him compensatory damages. While the jury was deliberating on an appropriate amount of punitive damages (entitlement to punitive damages had already been determined in his favor) the case settled for a confidential amount, now widely reported to exceed two million dollars.
The second trial court decision of great interest in this area is the now rather well known Schultz
v. Humana case out of Texas. Corpus Christi, Texas physician John Paul Schultz fought a long running legal battle with Humana over his expulsion from it's panel allegedly due to poor patient care. The case culminated in a seven week jury trial at the end of which the jury awarded Dr. Schultz $20,000,000.
The facts of the case are complicated and bitterly disputed. Schultz practiced primary care for 45 years. Humana asserts Dr. Schultz was an aging physician out of touch with numerous modern patient care issues. They reviewed his work in a peer review committee for many months and finally determined to terminate him. He was given a full disciplinary committee hearing, which he won, the committee recommending that he not be terminated but that certain aspects of his care be monitored. Following the additional monitoring called for by the committee hearing, Humana's peer review committee again recommended his expulsion. Rather than go through another full peer review hearing, he filed suit.
Dr. Schultz's version of the facts is that he strongly disagreed with Humana's new policy to encourage all the physicians to use a hospitalist system for their hospitalized patients. He alleges that dispute, as well as other criticisms he leveled against Humana made the local Humana medical director deeply hostile to him and determined to get rid of him. He claims many irregularities in the peer review that was orchestrated and run by the medical director and that ultimately when he was expelled, a large number of his patients were given to the Humana hired hospitalist who had also been an active participant on the peer review committee that expelled him. The jury's verdict makes it very clear they believed Dr. Schultz and disbelieved Humana, particularly the local medical director, who was himself a named defendant, and against whom the jury awarded punitive damages of $6 million.
Of additional interest is that a Humana pre-trial motion for summary judgment invoking the qualified immunities provided by HCQIA and the Texas Medical Practice Act, was denied on the grounds plaintiff had sufficient evidence to get to a jury on the issue of whether the peer review was conducted in bad faith and therefore outside of the protections of HCQIA and the Texas Medical Practice Act.
Finally, an interesting settlement was reported by BNA regarding seven New Jersey psychologists as well as the New Jersey Psychological Association. It seems in the late Fall of 2000, the psychologists entered into an undisclosed financial settlement to resolve their 1996 lawsuit against a managed care organization that dropped them from its provider network without cause, under a settlement announced Oct. 24 ("New Jersey Psychological Association
v. MCC Behavioral Care Inc.")
The settlement among the psychologists, the New Jersey Psychological Association, and CIGNA Behavioral Health Inc., which was known as MCC Behavioral Care Inc. until 1999, ended a lawsuit in which the psychologists claimed their termination under a contract clause that allowed terminations without cause violated New Jersey public policy. In addition to its financial provisions, the settlement required the company to offer the seven plaintiff psychologists the opportunity to rejoin CIGNA Behavioral Health's New Jersey professional network, according to a summary issued jointly by the American Psychological Association, the New Jersey Psychological Association, and CIGNA.
[1].
Medical Insurance Exchange of California 1995 California Large Loss Trend
Study.
[2]
Tex. Civ. Prac.
& Rem. Code §88.001 et seq.
[3] Corporate Health Insurance
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Cir.) decided 20 June 2000
[4]
Illinois
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[5].
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[6] For
a passionate opinion decrying the lack of remedies under ERISA, see Andrews-Clarke
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[7]
724
A.2d 889 (Pa., Dec. 1998)
[8] 514
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[9] 179
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[10]
1999 W.L. 161533 (N.Y.)
[11] 514
U.S. 645, 115 S. Ct. 1671 (1995).
[12]
This
case is really consistent with the new cases in that plaintiff claimed a
failure to provide certain services was malpractice.
The court correctly identified this as a coverage dispute, not a
malpractice claim.
[13] 154
F.3d 362 (7th Circuit 1998) reversed by the U.S. Supreme Court
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[14].
211 N.E.2nd 253
[15].
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[16].
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[17].
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[18].
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[19].
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[20].
14 Employee Benefits Cases 1556, 1991 WL 277590 (Mich. Cir. Ct., Sept. 17,
1991).
[21].
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[22].
604 A.2d 1053 (Pa.App.1992).
[23].
516 N.E.2d 1104 (Ind.App.1987).
[24].
595 N.E. 153 (Ill. App. 1992).
[25].
Hetzel-Lancaster v. Chandra, 1994
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[26]
296 Ill. App.3d 849, 696 N.E.2d 356 (1998)
[27]
301 Ill. App.3d 103, 703 N.E. 2d 502 (1998)
[28].
238 Conn. 216, 680 A.2d 127 (1996)
[29].
514 U.S. 645, 115 S. Ct. 1671, 131 L.Ed.2d 695 (1995).
[30].
140 N.H. 770, 674 A.2d 962 (1996).
[31].
27 C.A.4th 1598 (1994).
[32].
899 F.Supp. 438 (N.D.Cal. 1995).
[33] Louis
E. Potvin, M.D. v. Metropolitan Life Insurance Company 22
Cal.4th 1060 (2000)
