Problem 11.1: Ms. Joan Grant
Ms. Joan Grant was a 45-year-old attorney in private practice. She was enrolled
in the GoodHealth health maintenance organization (HMO) through her law
firm’s self-insured employee benefit plan. Generally, she had been in good
health, got plenty of exercise, and ate oat bran for breakfast every morning.
On the evening of April 15, 1996, while she was rushing to finish her tax
return, she developed a splitting headache. She decided that she would have
to obtain an extension to file her tax return. Because her doctor’s office was
closed for the night, she asked a friend to drive her to the emergency department
of Community General Hospital (Community). She arrived at Community
at approximately 9:30 p.m.
Community is an acute-care general hospital licensed by the state; it participates
in the Medicare program. It is owned and operated by General Hospital
Corporation, which is a for-profit business corporation.
Community has arranged for 24-hour medical coverage of its emergency
department by means of a contract with Village Emergency Physicians, P.A.
(VEPPA), which employs Dr. Ellen Jones and three other physicians. The contract
between Community and VEPPA states that Dr. Jones and the other physician
employees of VEPPA are not employees or agents of the hospital and further
states that the hospital will not be liable for any negligence by VEPPA or its physician
employees. In that regard, the hospital has placed the following sign on the
wall in the emergency department:
Community General Hospital wants you to know
that the physicians working in the emergency
department are employees of VEPPA and are
not employees or agents of the hospital.
Have a nice day!
On her arrival at Community’s emergency department, Ms. Grant told the
nurse on duty that she had a splitting headache, and she was briefly examined
by nurse Rebecca Smith. Then she was examined by the doctor on duty, Dr.
Jones. Ms. Grant had no prior relationship with Dr. Jones.
According to the hospital’s written protocols for the emergency department,
if an adult patient complains of a splitting headache and if that patient
does not appear to be intoxicated, the patient should be given a computed
tomography (CT) scan of the head as soon as possible. In addition to being
226 P a t i e n t C a r e I s s u e s
Community’s protocol, that method of diagnosis is the ordinary practice at all
of the hospitals in the area. However, some of the third-party payers have begun
to refuse to pay for CT scans under these circumstances.
Nurse Smith asked Ms. Grant about her health insurance. Ms. Grant said
that she was covered by the GoodHealth HMO and gave Nurse Smith an HMO
membership card that contained her policy number and a phone number for
the HMO. Nurse Smith called the office of the HMO to verify Ms. Grant’s coverage
and to request authorization for the CT scan. However, the clerk on duty
at the HMO informed Nurse Smith that GoodHealth HMO no longer pays for CT
scans of the head under these circumstances. Instead, the HMO clerk said that
the hospital should instruct Ms. Grant to call her primary care physician at the
HMO when the office opened at 9 a.m. the next day.
Nurse Smith informed Dr. Jones of the HMO’s decision, and Dr. Jones discharged
Ms. Grant at 10:30 p.m. with instructions to call her primary care physician
at the HMO the next morning. Dr. Jones did not tell Ms. Grant that the usual
diagnostic test for her condition was a CT scan, which Ms. Grant could have
paid for with the credit card that she carried in her wallet.
Ms. Grant’s friend took her home, where she died of an aneurysm at approximately
11:45 p.m. that night. At the request of the next of kin, an autopsy was
performed on the body of Ms. Grant. According to the autopsy report, Ms. Grant
died of a rare type of aneurysm that does not show up on a CT scan.
What claims could be asserted against Community by Ms. Grant’s estate?
In discussing each potential claim against Community, be sure to discuss the
elements of each claim and the likelihood of success on each claim.
Note: In responding to these questions, do not discuss any potential claims
against individual healthcare professionals, VEPPA, the GoodHealth HMO, or
the law firm’s health plan.
Problem 11.1: Ms. Joan Grant