Wickline v. State of California
1986 Cal. App. LEXIS 1870, 192 Cal. App. 3d 1630, 228 Cal. Rptr. 661 (1986)
Rule of Law:
Third-party payors of health care services can be held liable for medically inappropriate decisions resulting from defects in the design or implementation of cost-containment mechanisms, but they are not liable when a treating physician makes the ultimate medical decision to discharge a patient without protesting the payor's denial of coverage.
Facts:
- Plaintiff Wickline suffered from Leriche’s Syndrome and underwent major surgery by Dr. Polonsky to insert a synthetic graft in her artery.
- Following complications and two additional surgeries, Dr. Polonsky determined it was medically necessary for Wickline to remain in the hospital for eight additional days.
- Dr. Polonsky submitted a request for this extension to Medi-Cal, the state's medical assistance program.
- Dr. Glassman, a Medi-Cal consultant, reviewed the request and authorized only four additional days instead of eight, without personally examining Wickline or contacting her treating physicians.
- Although Dr. Polonsky believed the full eight days were necessary, he felt intimidated by the Medi-Cal process and discharged Wickline after the four authorized days without filing an appeal or requesting a further extension.
- Shortly after discharge, Wickline experienced pain and discoloration in her leg but did not immediately contact her doctors.
- Nine days after discharge, Wickline was readmitted to the hospital with a severe infection and total clotting in her leg.
- Due to the infection and lack of circulation, Dr. Polonsky was forced to amputate Wickline’s leg, testifying later that the leg likely would have been saved had she remained in the hospital for the originally requested duration.
Procedural Posture:
- Wickline sued the State of California (Medi-Cal) in the trial court for negligence.
- The case proceeded to a trial by jury.
- The jury returned a verdict in favor of Wickline and judgment was entered for the plaintiff.
- The State of California filed an appeal to the California Court of Appeal challenging the judgment.
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Issue:
Is a third-party health care payor liable for negligence when it denies a requested extension of hospitalization and the patient suffers harm after being discharged, where the treating physician complied with the denial without filing a further appeal or protest?
Opinions:
Majority - Rowen
No, the third-party payor is not liable because the treating physician retained the ultimate medical responsibility for the decision to discharge the patient. The court reasoned that while cost-containment programs are a reality of modern medicine, they must not corrupt medical judgment. Negligence liability arises from a breach of duty; here, the duty to determine medical necessity and discharge readiness rests primarily with the treating physician. Dr. Polonsky had the right and obligation to appeal the Medi-Cal decision or keep the patient hospitalized if he believed it was critical, regardless of payment authorization. By complying with the Medi-Cal authorization without protest, the physician accepted the responsibility for the discharge. The court found that Medi-Cal did not 'override' the physician's judgment because the physician did not utilize available mechanisms to challenge the initial denial.
Analysis:
This seminal case addresses the intersection of medical malpractice and insurance cost-containment programs. It establishes a limit on the liability of third-party payors (insurers/state programs), holding that they are generally not liable for patient harm resulting from a denial of care if the treating physician accepts that denial without utilizing available appeal processes. It emphasizes that the physician's duty to the patient supersedes financial pressures. However, the court leaves the door open for payor liability if the cost-containment system itself is defectively designed or if appeals are arbitrarily ignored, thereby corrupting medical judgment.
