Jones v. Chicago HMO Ltd. of Illinois

703 N.E.2d 502, 301 Ill. App. 3d 103, 234 Ill. Dec. 641, 1998 Ill. App. LEXIS 774
CourtAppellate Court of Illinois
DecidedNovember 12, 1998
Docket1-97-3821
StatusPublished
Cited by6 cases

This text of 703 N.E.2d 502 (Jones v. Chicago HMO Ltd. of Illinois) is published on Counsel Stack Legal Research, covering Appellate Court of Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Jones v. Chicago HMO Ltd. of Illinois, 703 N.E.2d 502, 301 Ill. App. 3d 103, 234 Ill. Dec. 641, 1998 Ill. App. LEXIS 774 (Ill. Ct. App. 1998).

Opinion

JUSTICE WOLFSON

delivered the opinion of the court:

Given the expanding role of managed health care, the issues raised in this medical negligence lawsuit were bound to reach the courts.

Sheila Jones (Jones), individually and as mother of Shawndale Jones (Shawndale), presents three separate legal theories in her effort to hold Chicago HMO liable for the negligent acts of one of its contract doctors. The trial court granted summary judgment to the defendant, rejecting all three theories. We agree there was. no fact issue meriting a trial on two of those theories, but we find summary judgment was erroneously granted on a third.

Jones’ second amended complaint against Chicago HMO consists of three counts. Count I is entitled “Institutional Negligence,” another way of referring to independent corporate negligence. Count II is entitled “Vicarious Liability” and contends Chicago HMO, as principal, is liable for the negligent acts of its agent, Dr. Robert A. Jordan (Dr. Jordan). Count III, referred to as “Contract Liability,” contends Chicago HMO breached its contractual obligations to the plaintiff.

Thus far, two Illinois decisions have dealt with the question of whether a health maintenance organization (HMO) may be held liable for the negligence of a contract physician.

The first was Raglin v. HMO Illinois, Inc., 230 Ill. App. 3d 642, 595 N.E.2d 153 (1992). The second was Petrovich v. Share Health Plan of Illinois, Inc., 296 Ill. App. 3d 849, 696 N.E.2d 356 (1998), appeal allowed, 179 Ill. 2d 616 (1998).

Both cases observed that a potential exists for HMOs to be held liable for medical malpractice under more than one theory. Raglin held, and Petrovich agreed, the theories include:

“(1) vicarious liability on the basis of respondeat superior or ostensible agency; (2) corporate negligence based upon negligent selection and negligent control of the physician; and (3) corporate negligence based upon the corporation’s independent acts of negligence, e.g., in the management of utilization control systems. Contract law might also be utilized to hold HMOs liable for malpractice based on breach of contract or breach of warranty.” Raglin, 230 Ill. App. 3d at 646.

Accord Petrovich, 296 Ill. App. 3d at 855.

Raglin cited an article in the American Bar Association’s Tort and Insurance Law Journal as the sole support for its summary of available theories. Petrovich cited Raglin. The only issues actually decided in those cases had to do with vicarious liability. Until now, no Illinois medical malpractice case has dealt with claims of HMO independent corporate negligence and breach of contract with covered patients.

Raglin and Petrovich stand for the proposition that while HMOs are not immune from civil prosecution for malpractice, some recognized legal theory must be satisfied before liability can attach.

With that background, we turn to the facts necessary for consideration of the issues in this case.

FACTS

There are two contracts to examine in this case. One is the 1990 “AGREEMENT FOR FURNISHING HEALTH SERVICES” between Chicago HMO and the Illinois Department of Public Aid (IDPA) to provide health care' services to Medicaid recipients (Beneficiaries). Jones, a Medicaid recipient, and her children fall under the agreement’s definition of beneficiaries.

The second contract is the 1990 agreement between Chicago HMO and Dr. Jordan, the pediatrician charged with negligence in this case.

The preamble to the agreement between Chicago HMO and IDEA said: “[Chicago HMO] meets the State Plan definition of an HMO, namely that [Chicago HMO] *** is organized primarily for the purpose of providing health care services ***.” The preamble continued: “[Chicago HMO] warrants that it is able to provide the medical care and services required under this Agreement in accordance with prevailing community standards, and is able to provide these services promptly, efficiently, and economically ***.”

Article V of this agreement also described Chicago HMO’s duties. In article V section (b), Chicago HMO agreed to “provide or arrange to have provided all covered services to all Beneficiaries under this Agreement.” In article V section (m), Chicago HMO further agreed to “provide all Beneficiaries with medical care consistent with prevailing community standards” and to implement a quality control program in compliance with federal regulations. In article V section (n), Chicago HMO agreed to afford each Beneficiary a primary care physician (PCP) to supervise and coordinate medical care. Section (n) of the agreement provided:

“There shall be at least one full-time equivalent, board eligible physician to every 1,200 [Beneficiaries], including one full-time equivalent, board certified primary care physician for each 2,000 [Beneficiaries]: *** There shall be *** one pediatrician for each 2,000 [Beneficiaries] under age 17.”

Article V, section (q)(3), of the agreement said: “[Chicago HMO] shall remain responsible for the performance of the subcontractor [physicians].” Article EX, section (1), of the agreement said: “The relationship of [Chicago HMO] to the [IDPA] arising out of this Agreement shall be that of an Independent Contractor.”

A “MEDICAL SERVICE GROUP AGREEMENT” described the relationship between Chicago HMO and Dr. Jordan:

“The [HMO] and the [physician] are separate and independent entities, and each is an independent contractor. Neither party is the partner, agent or representative of the other; neither shall have any direction or control over the manner in which the other performs its services and functions; each is free to enter into contracts with other entities ***.”

This agreement also listed Dr. Jordan’s duties in detail. Dr. Jordan would provide to Chicago HMO subscribers specified medical services “of good quality and in accordance with accepted medical and hospital standards of the community”; maintain medical records “in such form as required by the medical director of [the HMO] and make these records available to the HMO for inspection”; and “cooperate with and participate in the Quality Assurance and Utilization Review Programs of the [HMO].” Additionally, under a “PUBLIC AID AMENDMENT TO THE MEDICAL GROUP SERVICE AGREEMENT,” Dr. Jordan agreed “to abide by any conditions imposed by the [HMO] as part of the [HMO’s] agreement with the [IDPA].”

According to Dr. Jordan, Chicago HMO contract physicians would use their own medical judgment to decide on an HMO subscriber’s course of treatment. However, under the agreement, this medical judgment was subject to review: if Chicago HMO disagreed with the physician about the medical necessity of certain treatment, an independent review physician, jointly selected by the subscriber, the contract physician, and Chicago HMO would determine medical necessity.

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Related

Jones v. Chicago HMO Ltd. of Illinois
730 N.E.2d 1119 (Illinois Supreme Court, 2000)
Jones v. Chicago HMO Ltd.
Illinois Supreme Court, 2000
Petrovich v. Share Health Plan of Illinois, Inc.
719 N.E.2d 756 (Illinois Supreme Court, 1999)

Cite This Page — Counsel Stack

Bluebook (online)
703 N.E.2d 502, 301 Ill. App. 3d 103, 234 Ill. Dec. 641, 1998 Ill. App. LEXIS 774, Counsel Stack Legal Research, https://law.counselstack.com/opinion/jones-v-chicago-hmo-ltd-of-illinois-illappct-1998.