HMO provider group of physicians does not provide timely hand surgery. $7.2M. Los Angeles County.
Following a bad hand injury, plaintiff receives referral after referral through his HMO, but no timely surgery.
- Case Name: Terry J. LaRue v. Health Net of California, Inc.; Accountable Health Care IPA, A Professional Medical Corporation; Roe physician, and Does 1 through 100, inclusive
- Court and Case Number: Los Angeles Superior Court / BC566095
- Date of Verdict or Judgment: Thursday, May 04, 2017
- Date Action was Filed: Tuesday, December 09, 2014
- Type of Action: Breach of Contract, Insurance – Bad Faith, Claims Handling, Medical Malpractice
- Judge or Arbitrator(s): Hon. Malcolm Mackey
- Plaintiffs: Terry J. LaRue, 28, freelance sports videographer.
- Defendants: Accountable Health Care IPA, A Professional Medical Corporation
- Type of Result: Jury Verdict
- Gross Verdict or Award: $7,225,000
- Award as to each Defendant:
Defendants Health Net of California, Inc. and Roe physician settled prior to trial. Their settlement amounts totaled to $4,050,000.
- Economic Damages:
- Non-Economic Damages:
- Trial or Arbitration Time: 2 1/2 weeks.
- Jury Deliberation Time: 1 day.
- Jury Polls: 12-0
- Attorney for the Plaintiff:
Gianelli & Morris, A Law Corporation by Robert Gianelli, Los Angeles.
The Kern Law Group, PC by Rene Kern, Los Angeles.
- Attorney for the Defendant:
McClelland Advocacy, Ltd by Michael McClelland, Rocklin.
- Plaintiff’s Medical Expert(s):
Joshua Prager, M.D., pain management, Los Angeles.
Milan Stevanovic, M.D., hand surgery, Los Angeles.
- Defendant's Medical Expert(s):
David Fish, M.D., pain management, Santa Monica.
George Macer, M.D., hand surgeon, Long Beach.
- Plaintiff's Technical Expert(s):
Rick Sarkisian, vocational rehabilitation, Fresno.
Sharon Kawai, M.D., life care planning, Fullerton.
Timothy Lanning, economics, Santa Ana.
- Defendant's Technical Expert(s):
Steve Molina, Ph.D., vocational rehabilitation, San Clemente.
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.
Injuries and Other Damages
- Physical Injuries claimed by Plaintiff:
Plaintiff sustained a Bennett’s fracture to his thumb that required surgery within 10-14 days to avoid permanent problems. Through a series of mishaps relating to Accountable IPA’s failure to have sufficient hand surgeons available in the network, it took plaintiff six and a half weeks to get surgery on his hand. Because the bone had healed in a misaligned position, it had to be re-broken and re-set. The untreated thumb fracture and re-breaking resulted in Complex Regional Pain Syndrome and loss of use of plaintiff's left hand.
Plaintiff has minimal movement of his left thumb, cannot hold or pick up anything that involves the use of his thumb, and experiences constant pain, swelling and weakness. He can no longer grip a camera with both hands, causing him significant financial loss to his profession as a freelance sports videographer.
- Special Damages Claimed - Future Medical: $2,500,000
- Special Damages Claimed - Future Lost Earnings: $1,300,000
Demands and Offers
- Plaintiff Final Demand before Trial: Burning policy limit demand of $850,000 to defendant Accountable.
- Defendant §998 Offer: $401,000