Introduction
When patients suspect medical malpractice by a healthcare provider, they hope the lawsuit or insurance claim will prevail. However, many claims are rejected or thrown out. By learning why claims get rejected, patients and family members can do the right things and tip the odds in winning.
Below are the most common reasons under which the malpractice claims are denied inside the U.S., what the requirements are by law, and how to avoid pitfalls.
What Is Medical Malpractice?
Medical malpractice is Prior to an explanation on the grounds of denial, it is necessary to understand what is required to be an arguable medical malpractice action. You will normally need to demonstrate the following to be successful:
- Duty of care: The medical professional owed a legal duty to the patient.
- Breach of duty (negligence): The professional failed to take the accepted standard of care.
- Causation: That breach actually caused injury.
- Damages: There was an injury (physical harm, consequential medical costs, suffering and pain, etc.).
- Statute of limitations: The action was brought within the time the statute permitted.
Lack of any one of these elements can cause the malpractice claim to be dismissed and denied. They themselves are legal terms (duty, breach, causation, damages, statute of limitations, expert witness, standard of care).
Top Reasons Why Malpractice Claims Are Denied
These are the most typical grounds why malpractice claims are denied in the U.S., together with explanations and illustrations. Most are not satisfying any of the requirements listed above, or are not satisfying procedural requirements.
1. Statute of Limitations Expired
- Each state has its own time limitation to sue for medical malpractice. When you sue after that time frame has passed, the court will generally dismiss the action, period.
- Some also include a statute of repose, an absolute time limitation after which no action can be brought, regardless of the date the damage is discovered.
- Occasionally, the time it begins to run only runs once the patient has uncovered (or ought reasonably to have uncovered) the wound, but the action is still statute-barred.
2. Absence of Expert Witness or Certificate of Merit
- As to proving breach of duty and causation, most require expert medical testimony. Without being able to get the proper expert, or if the expert fails to meet the state grounds (specialty, experience, etc.) to be qualified, the court can dismiss the case.
- Most also require a certificate of merit or affidavit of merit at the beginning of the case, affirming by oath that, to the medical professional’s mind, there is merit to the action. Without this timely production, the court can dismiss.
3. Lack of Proof on Standard of Care and Breach
- Unless the plaintiff can also prove what the accepted standard medical care was and how the provider did not meet it, the court can also deny the case.
- The standard of care is usually set by expert witnesses.
- Where the testimony is weak, inconsistent, or excluded, the breach element is deficient.
4. Lack of Proof of Causation
- Even where negligence (breach) is proven, you will be called upon to prove directly that the breach caused injury.
- Where the causation is speculative or can be proven by expert testimony, the claim will be thrown out.
- Some jurisdictions require proof that a medical occurrence did take place with reasonable medical probability, not possibility, a medical occurrence.
5. No Actual Damages
- Unless there is damage or injury, not physical damage, not further medical costs, not some recognized kind of mental anguish, then damages do not come to life, and the action fails.
- Error by the court alone is frequently insufficient.
6. Assumption of Risk or Contributory/Comparative Negligence
- Otherwise, the damage will be the fault of the patient through their own actions.
- Comparative negligence or contributory negligence can reduce or deny the recovery, by statute.
- I.e. Patient fails to obey instructions on post-operative care, or waits to come after noting the symptoms.
7. Issues of Consent (Informed Consent Not Provided or Insufficient)
Medical professionals are required to obtain informed consent. Patients need to be informed about the risks and benefits and alternatives.
If something goes awry that the patient wasn’t adequately cautioned about, that omission can be the basis for malpractice.
However, where the risk was known, accepted, or well-known, the said defense (informed consent) can cause denial of claim.
8. Procedural or Technical Errors
- Incorrect filing of the case, failure to timely file, failure to serve adequate notice (pre-suit notice in others), wrong court, wrong defendant.
- Breach of procedural rules may result in the claim being dismissed.
9. Lack of Recording or Incorrect Medical Records
- Documentation is the way to prove what happened.
- If there is documentation lost, inaccurate, inconsistent, or altered, the other party can claim the plaintiff is unable to produce sufficient evidence.
- Moreover, it can hurt your case to wait to obtain or produce medical records.
10. Injury Was Not Reasonably Foreseeable or Beyond the Provider’s Control
- Unless the damage was not reasonably foreseeable, or there always occurred some intervening cause (some other party’s action, unexpected risk, etc.), then causation or breach would be negated.
11. Treatment Was Within Accepted Standards (No Negligence)
- Once in a while, the thing that went wrong is recognized but falls within an accepted risk of medicine. Complications can occur without proper medical attention. Where the provider acted within accepted norms, the aspect of breach fails.
12. Emergency Exception / Defense of Necessity
- For emergency procedures where instant action is required, and there is not enough time to adhere to ordinary procedures, any claims of negligence can be denied if the provider’s actions became reasonably necessary within the situation.
13. Settlement or Agreement Already Reached
- Where the patient consented to a release by settling earlier and agreeing to an arbitration or mediation and relinquishment of the right to other claims, the latter claims can be prevented by virtue of contractual waiver.
State Specific Examples & Law Requirements
- A majority of the states also possess Certificate of Merit / Affidavit of Merit statutes that require plaintiffs to submit at an early time an expert’s affidavit that there is a viable action of malpractice.
- Ohio also has the requirement to file the malpractice suits within one year after the action has accrued or the injury has been perceived, but it also has a four-year statute of repose that is applicable.
- In Florida, plaintiffs must sometimes undergo a pre-suit investigation and provide an affidavit from a medical expert before formal filing.
How to Avoid Having Your Malpractice Claim Denied
Patients or lawyers should not reduce the risk of denial:
- Act now, do not let the statute of limitations run; get evidence together quickly.
- Find qualified medical expert witnesses who meet the needs of your state (specialty, experience).
- Current medical records include all the physician’s documentation, test results, and imaging studies.
- Standard of care and negligence are defined precisely expert testimony should indicate what would be undertaken by the ordinary provider.
- Establish causation conclusively prove a direct relationship between the provider’s violation and damage, not potential.
- Verify that informed consent processes had been used; list the risks informed to you.
- Following procedural rules mandated notice before suit, proper filing of jurisdiction, proper defendants, affidavits, or certificates of merit.
- Watch out for intervening causes if another event could have caused it; cover that in your evidence.
Conclusion
Malpractice claims are nuanced. Most are denied more due to the absence of one or more of the key legal or procedural requirements, rather than the notion of malpractice is far-fetched. Statute of limitations, absence of expert witness, failure to establish standard of care, absence of causation or damages, and tech/procedural flaws are some of the leading causes claims get denied.
If you think you’ve been harmed by medical negligence, speak with an attorney who has strong medical malpractice experience in the state where the involvement occurred. Early investigation, strong expert testimony, and timely completion of requirements help to sidestep denial and the potential for success.
Frequently Asked Questions (FAQs)
Medical malpractice claims often fail because one or more of the legal requirements are not present, for instance, an expired statute of limitations, failure to present expert testimony, failure to establish the standard of care, poor proof of causation, lack of actual damages to the patient, or procedural errors in filing or in pre-suit requirements.
In most malpractice claims, there is a need for an expert witness, as they establish the standard of care and explain how the healthcare provider breached that standard. Experts also help prove causation. Without a qualified expert or a required certificate of merit, courts may dismiss such claims at early points in the process.
Yes, even in instances where there is evidence of a medical mistake, the patient may get a denial of the malpractice claim. The courts understand that not every mistake gives rise to a cause of action. Without an injury, additional costs, or legally cognizable suffering, the claim may fail.
Every state has a statute of limitations within which a malpractice claim must be filed. If filed after the limit has lapsed, courts will dismiss an action even if it has merit. Many states also have a statute of repose, which is an absolute time limit on when a case can be brought, regardless of actual injury discovery.
To limit the possibility of denial of the claim, the patient should not delay, should preserve the medical record, must work with competent medical professionals, and also follow all rules of procedure. The elements necessary to sustain a valid claim of malpractice include standard of care, causation, damages, and informed consent.