In this medical malpractice action, defendant, HIP of New Jersey, a health maintenance organization (commonly known as an HMO) moves for summary judgment claiming statutory immunity from medical malpractice under N.J.S.A. 26:2J-25. The court holds that the statute does not grant such immunity to the HMO itself, but grants such immunity only to persons participating in the arrangements of an HMO who are not actual providers of health care services or supplies to enrollees and their families.
Plaintiff's decedent, Lorraine Robbins maintained health insurance benefits with defendant, HIP of New Jersey, from 1986 through 1987 during which time she was diagnosed and treated for breast cancer. This action alleges professional negligence in the diagnosis and treatment of her cancer and seeks damages from the medical personnel who treated her as well as from the defendant, HIP.
Defendant, HIP, moves for summary judgment arguing that it is entitled to immunity from professional negligence claims brought in connection with the furnishing of health care services
and supplies pursuant to N.J.S.A. 26:2J-25(c) and (d) which provide as follows:
"c. Any health maintenance organization authorized under this act shall not be deemed to be practicing medicine and shall be exempt from the provisions of chapter 9 of Title 45, Medicine and Surgery, of the Revised Statutes relating to the practice of medicine."
"d. No person participating in the arrangements of a health maintenance organization other than the actual provider of health care services or supplies directly to enrollees and their families shall be liable for negligence, misfeasance, nonfeasance or malpractice in connection with the furnishings of such services and supplies."
HMOs were authorized pursuant to the " Health Maintenance Organization Act," N.J.S.A. 26:2J-1, et seq. effective December 27, 1973. N.J.S.A. 26:2J-2 contains the following pertinent definitions:
"f. 'Health maintenance organization' means any person which directly or through contracts with providers furnishes at least basic comprehensive health care services on a prepaid basis to enrollees in a designated geographical area."
"g. 'Person' means any natural or artificial person including but not limited to individuals, partnerships, associations, trusts, or corporations."
"h. 'Provider' means any physician, hospital, or other person which is licensed or otherwise authorized in this State to furnish health care services."
The general scheme of the enabling act is to authorize the State Commissioner of Health to grant certificates of authority to HMOs upon application if they comply with the statutory criteria. N.J.S.A. 26:2J-3 and 2J-4. HMOs are authorized to receive funds by loan or otherwise; to purchase, lease, contract and maintain health care facilities and ancillary equipment; to make loans to medical groups under contract to the HMO and to assume responsibility for the furnishing of health care services through providers which are under contract with or employed by the HMO to persons including but not limited to enrollees. HMOs are also authorized to contract with others to have them perform on behalf of the HMO certain functions such as marketing, enrollment and administration. HMOs also may contract with an ...