Editorials

SAN FRANCISCO — About 1.5 million California seniors covered by Medicare-contracted HMOs got a legal boost Thursday from the state’s highest court, which ruled they can sue their health maintenance organizations for damages. 

California seniors became stuck in a legal limbo in 1998, when a lower court ruled that the disabled and those 65 and older enrolled in a Medicare HMO only could pursue federal administrative claims to get the services they alleged were withheld. 

Legal experts said the 1998 decision was the nation’s only such ruling, which affected California seniors and the disabled who contracted their Medicare benefits to an HMO. 

“This brings California in line with all of the federal courts and the rest of the country,” said Carol S. Jimenez, a Los Alamitos lawyer representing the wife of a deceased Costa Mesa man whose attorneys claimed he was denied a lung transplant for cost reasons. Ruling 5-2, the court said seniors and the disabled on Medicare can sue their HMO in California courts for damages on allegations of injuries sustained because of a lack of care. Those damages could add up to millions of dollars. 

That option generally is not available to the nation’s non-Medicare patients who subscribe to employer-financed HMOs. 

“This decision from the Supreme Court is a very significant patients’ rights case for those on Medicare,” said Jeffrey Ehrlich, a Claremont attorney representing several seniors now free to pursue their damage claims against their Medicare HMOs. 

Jeff Grass, an Upland attorney defending the Southern California physicians in the case, said the decision may usher in more suits against doctors and their HMOs. 

“I don’t think that this is good,” Grass said. “The people I’ve represented have all been patient oriented. I’ve never seen any abuse.” 

The case decided Thursday, signed by Justice Kathryn Mickle Werdegar, concerned the disabled Costa Mesa man on Medicare who sued Pacificare of California Inc. and others for denying the lung transplant. George McCall, who later died, alleged he did not receive one because of cost-cutting moves. 

Pacificare says it did not deny the transplant, but instead denied McCall his choice of hospitals, said Ben Singer, a company spokesman. 

The case is McCall v. Pacificare of California, S082236.