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Ultrasound delay leads to landmark case before High
Court
Posted
10-11-99 Washington. The U.S. Supreme Court placed itself in the middle of the HMO debates with its Sept. 28 decision to accept a case about whether an Illinois HMO breached its legal duty to a patient whose appendix burst during an eight-day wait for an ultrasound. At issue is whether the HMO's financial structure, in which physicians' compensation is based in part on their ability to hold down costs, prevented the best interests of the patient from being met, as is required by the federal Employee Retirement Income Security Act of 1974. ERISA applies to all health benefits provided through private employers. The patient, Cynthia Herdrich of Bloomington, Ill., went to her physician at the Health Alliance Medical Plans of Urbana, Ill., complaining of abdominal pain. The physician found an inflamed mass. The suit alleges that an ultrasound was then delayed for eight days so that it could be performed by the HMO. While waiting for the ultrasound, Herdrich's appendix burst, causing peritonitis. Herdrich sued her HMO for malpractice and won $35,000 in compensatory damages in an Illinois court. Her amended claims for fraud were transferred to Federal District Court, which ruled on the side of the health plan. Herdrich again amended the suit to include the charge of breach of fudiciary duty under ERISA. The Federal District Court dismissed that portion of the suit, but its decision was reversed by the 7th Circuit Court. The health plan asked the U.S. Supreme Court to review the 7th Circuit Court decision, and briefs were filed by a group of healthcare trade associations and the U.S. Chamber of Commerce. The Supreme Court agreed to review the case and will now decide whether patients can sue their employer-sponsored health plans for breach of fiduciary duty under ERISA law. A decision is not expected until next summer. "We thought the 7th Circuit Court's decision was very, very negative with respect to managed care and went outside the bounds of the ERISA law," said Louis Saccoccio, general counsel for the American Association of Health Plans, which participated in filing the brief. But Herdrich's attorney thinks the HMO is trying to switch horses midstream. "What strikes me as ironic in this case is that it was the defendant, the HMO, that initially argued that this issue was governed by ERISA," said James Ginzkey, the Bloomington attorney representing Herdrich. "Now, after receiving the benefits of the ruling, they want to change the rules."
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