HMO provider group of physicians does not provide timely hand surgery. $7.2M. Los Angeles County.

Facts and Background

• Facts and Background:

  Defendant, Accountable Health Care IPA, A Professional Medical Corporation ("Accountable"), entered into an agreement with Health Net of California, Inc. (“Health Net”) in October of 2013 to accept members enrolling in Health Net’s Affordable Care Act plan, the CommunityCare HMO plan. Accountable agreed to maintain an adequate network of primary care physicians and specialists and ensure that they had hospital privileges at CommunityCare network hospitals.

  On May 1, 2014, plaintiff Terry LaRue became covered under a Health Net IFP CommunityCare HMO plan. On May 5, 2014, while working as a freelance videographer, plaintiff fell and seriously injured his left hand. He went to an emergency room in Denver where he was diagnosed with a Bennett’s fracture – a fracture of the base of the first metacarpal bone – and was referred to an orthopedic surgeon to perform surgery the following day. The next day, plaintiff was informed that the surgeon would not accept his Health Net coverage.

  Over the next several weeks, plaintiff visited a series of orthopedic surgeons in the plan who each confirmed the immediate need for surgery, but could not provide the necessary treatment as they were not hand surgeons or contracted with the hospitals, and thus he kept getting referred to other specialists.

  Finally, after complaining multiple times to Health Net about the lack of a referral to a specialist, an appointment with Dr. Dwight Roberson was made for June 2 during which plaintiff's diagnosis was again confirmed and a surgery date was set. Seven weeks after first contacting Health Net about his condition, plaintiff's hand surgery took place on June 19, 2014.

  Due to the six-and-a-half week delay in receiving treatment, plaintiff suffered a permanent and significant impairment of his left hand, including not being able to hold or pick up anything involving the left thumb, constant pain, swelling and weakness. Plaintiff can no longer work as a professional action sports videographer causing him significant financial loss.

• Plaintiff's Contentions:

  That defendant Accountable Health Care IPA failed to authorize urgent surgery by an in-network hand surgeon resulting in a six-and-one-half-week delay in surgery. That this delay required a re-breaking of the fracture site and caused plaintiff to develop Complex Regional Pain Syndrome. Plaintiff claimed negligence and violation of Civ Code 3428.

  Claims against settling defendants: Claim against Health Net was for breach of the implied covenant of good faith and fair dealing and violation of Civ Code 3428 (statutory cause of action against managed care entities); medical negligence against Roe physician. 

• Defendant's Contentions:

  Accountable contended that it did not deny any requests for authorization and relied on the expertise of the given orthopedic surgeons as to how and when treatment should proceed; that multiple attempts were made by Health Net and Accountable to schedule surgery. However, although a series of orthopedic surgeons examined the plaintiff, they each decided not to operate and to refer the plaintiff to another specialist.

  Accountable also contended that the hand surgery was not the cause of plaintiff’s Complex Regional Pain Syndrome.