Title: Jones v. Chicago HMO Ltd.
Citation: N/A
Docket Number: 86830
State: Illinois
Issuer: Illinois Supreme Court
Date: May 18, 2000

Opinion filed May 18, 2000.
JUSTICE BILANDIC delivered the opinion of the court:
This appeal asks whether a health maintenance organization (HMO) may be held 
liable for institutional negligence. We answer in the affirmative.
The plaintiff, Sheila Jones (Jones), individually and as the mother of the 
minor, Shawndale Jones, brought this medical malpractice action against the 
defendants, Chicago HMO Ltd. of Illinois (Chicago HMO), Dr. Robert A. Jordan and 
another party. The Joneses were members of Chicago HMO, an HMO. Dr. Jordan was a 
contract physician of Chicago HMO and the primary care physician of 
Shawndale.
The circuit court of Cook County awarded summary judgment in favor of Chicago 
HMO on all three counts of Jones' second amended complaint. Count I charges 
Chicago HMO with institutional negligence. Count II charges Chicago HMO with 
vicarious liability for Dr. Jordan's alleged negligence under the doctrine of 
apparent authority. Count III charges Chicago HMO with breach of contract. The 
circuit court also entered a finding pursuant to Supreme Court Rule 304(a) (155 
Ill. 2d R. 304(a)). On appeal, the appellate court affirmed the grant of summary 
judgment as to counts I and III, but reversed the grant of summary judgment as 
to count II, remanding that claim for further proceedings. 301 Ill. App. 3d 103. 
We allowed Jones' petition for leave to appeal (177 Ill. 2d R. 315). Because 
Chicago HMO does not challenge the appellate court's reversal of count II, only 
counts I and III are at issue in this appeal.
Two organizations filed amicus curiae briefs with the permission of 
this court. See 155 Ill. 2d R. 345. The Illinois Association of Health 
Maintenance Organizations filed a brief in support of Chicago HMO. The Illinois 
Trial Lawyers Association filed a brief in support of Jones. For the reasons 
explained below, we affirm the summary judgment as to count III, breach of 
contract, but we reverse the summary judgment as to count I, institutional 
negligence, and remand that claim for further proceedings.
FACTS
In reviewing an award of summary judgment, we must view the facts in the 
light most favorable to the nonmoving party. Petrovich v. Share Health Plan 
of Illinois, Inc., 188 Ill. 2d 17, 30-31 (1999). The following facts thus 
emerge.
On January 18, 1991, Jones' three-month-old daughter Shawndale was ill. Jones 
called Dr. Jordan's office, as she had been instructed to do by Chicago HMO. 
Jones related Shawndale's symptoms, specifically that she was sick, was 
constipated, was crying a lot and felt very warm. An assistant advised Jones to 
give Shawndale some castor oil. When Jones insisted on speaking with Dr. Jordan, 
the assistant stated that Dr. Jordan was not available but would return her 
call. Dr. Jordan returned Jones' call late that evening. After Jones described 
the same symptoms to Dr. Jordan, he also advised Jones to give castor oil to 
Shawndale.
On January 19, 1991, Jones took Shawndale to a hospital emergency room 
because her condition had not improved. Chicago HMO authorized Shawndale's 
admission. Shawndale was diagnosed with bacterial meningitis, secondary to 
bilateral otitis media, an ear infection. As a result of the meningitis, 
Shawndale is permanently disabled.
The medical expert for the plaintiff, Dr. Richard Pawl, stated in his 
affidavit and deposition testimony that Dr. Jordan had deviated from the 
standard of care. In Dr. Pawl's opinion, upon being advised of a three-month-old 
infant who is warm, irritable and constipated, the standard of care requires a 
physician to schedule an immediate appointment to see the infant or, 
alternatively, to instruct the parent to obtain immediate medical care for the 
infant through another physician. Dr. Pawl gave no opinion regarding whether 
Chicago HMO was negligent.
Although Jones filed this action against Chicago HMO, Dr. Jordan and another 
party, this appeal concerns only counts I and III of Jones' second amended 
complaint, which are directed against Chicago HMO. Count I charges Chicago HMO 
with institutional negligence for, inter alia, (1) negligently 
assigning Dr. Jordan as Shawndale's primary care physician while he was serving 
an overloaded patient population, and (2) negligently adopting procedures that 
required Jones to call first for an appointment before visiting the doctor's 
office or obtaining emergency care. Count III charges Chicago HMO with breach of 
contract and is based solely on Chicago HMO's contract with the Department of 
Public Aid. Chicago HMO moved for summary judgment on both counts. Jones and 
Chicago HMO submitted various depositions, affidavits and exhibits in support of 
their positions.
Chicago HMO is a for-profit corporation. During all pertinent times, Chicago 
HMO was organized as an independent practice association model HMO under the 
Illinois Health Maintenance Organization Act (Ill. Rev. Stat. 1991, ch. 111½, 
par. 1401 et seq.).
In her deposition testimony, Jones described how she first enrolled in 
Chicago HMO while living in Park Forest. A Chicago HMO representative visited 
her home. According to Jones, he "was telling me what it was all about, that HMO 
is better than a regular medical card and everything so I am just listening to 
him and signing my name and stuff on the papers. *** I asked him what kind of 
benefits you get out of it and stuff, and he was telling me that it is better 
than a regular card."
The "HMO ENROLLMENT UNDERSTANDING" form signed by Jones in 1987 stated: "I 
understand that all my medical care will be provided through the Health Plan 
once my application becomes effective." Jones remembered that, at the time she 
signed this form, the Chicago HMO representative told her "you have got to call 
your doctor and stuff before you see your doctor; and before you go to the 
hospital, you have got to call."
Jones testified that when she later moved to Chicago Heights another Chicago 
HMO representative visited her home. This meeting was not arranged in advance. 
It occurred because the representative was "in the building knocking from door 
to door." Jones informed the representative that she was already a member.
When Jones moved to Chicago Heights, she did not select Dr. Jordan as 
Shawndale's primary care physician. Rather, Chicago HMO assigned Dr. Jordan to 
her. Jones explained:
Dr. Mitchell J. Trubitt, Chicago HMO's medical director, testified at his 
deposition that Dr. Jordan was under contract with Chicago HMO for two sites, 
Homewood and Chicago Heights. The service agreement for the Homewood site was 
first entered into on May 5, 1987. The service agreement for the Chicago Heights 
site was first entered into on February 1, 1990. Dr. Jordan was serving both 
patient populations in January of 1991 when Shawndale became ill.
Dr. Trubitt stated that, before Chicago HMO and Dr. Jordan executed the 
Chicago Heights service agreement, another physician serviced that area. Chicago 
HMO terminated that physician for failing to provide covered immunizations. At 
the time that Chicago HMO terminated that physician, Dr. Jordan agreed "to go 
into the [Chicago Heights] area and serve the patients." Chicago HMO then 
assigned to Dr. Jordan all of the patients of that physician. Dr. Trubitt 
explained:
Dr. Trubitt also explained that Dr. Jordan was Chicago HMO's only physician 
who was willing to serve the public aid membership in Chicago Heights. Dr. 
Trubitt characterized this lack of physicians as "a problem" for Chicago 
HMO.
Dr. Jordan testified at his deposition that, in January of 1991, he was a 
solo practitioner. He divided his time equally between his offices in Homewood 
and Chicago Heights. Dr. Jordan was under contract with Chicago HMO for both 
sites. In addition, Dr. Jordan was under contract with 20 other HMOs, and he 
maintained his own private practice of non-HMO patients. Dr. Jordan estimated 
that he was designated the primary care physician of 3,000 Chicago HMO members 
and 1,500 members of other HMOs. In contrast to Dr. Jordan's estimate, Chicago 
HMO's own "Provider Capitation Summary Reports" listed Dr. Jordan as being the 
primary care provider of 4,527 Chicago HMO patients as of December 1, 1990.
Jones' legal counsel and Dr. Trubitt engaged in the following colloquy 
concerning patient load:
In January of 1991, Dr. Jordan employed four part-time physicians, in 
addition to himself. This included an obstetrician/gynecologist, an internist, a 
family practitioner and a pediatrician. Dr. Jordan, however, did not explain in 
what capacities these physicians served. The record contains no further 
information regarding these physicians.
The record also contains evidence concerning Chicago HMO procedures for 
obtaining health care. Chicago HMO's "Member Handbook" told members in need of 
medical care to "Call your Chicago HMO doctor first when you experience 
an emergency or begin to feel sick." (Emphasis in original.) Also, Chicago HMO 
gave its contract physicians a "Provider Manual." The manual contains certain 
provisions with which the providers are expected to comply. The manual contains 
a section entitled, "The Appointment System/Afterhours Care," which states that 
all HMO sites are statutorily required to maintain an appointment system for 
their patients.
Dr. Trubitt testified that Chicago HMO encouraged its providers to maintain 
an appointment system and also "to retain open spaces on their schedules so that 
patients who came in as walk-ins could be seen." Retaining space on the schedule 
for walk-ins was recommended because it offers quicker access to care, keeping 
patients out of the emergency room with its increased costs, and because, 
historically, the Medicaid patient population often did not make or keep 
appointments.
Dr. Jordan related that his office worked on an appointment system and had 
its own written procedures and forms for handling patient calls and 
appointments. When a patient called and Dr. Jordan was not in the office, 
written forms were used by his staff or his answering service to relay the 
information to him. If Dr. Jordan was in the office, the procedure was as 
follows:
Three agreements appear in the record. First, Chicago HMO and the Department 
of Public Aid entered into a 1990 "AGREEMENT FOR FURNISHING HEALTH SERVICES." 
This agreement was "for the delivery of medical services to Medicaid recipients 
on a prepaid capitation basis." Jones and her children, Medicaid recipients, 
fall within the agreement's definition of beneficiaries.
The preamble to the agreement stated that Chicago HMO "is organized primarily 
for the purpose of providing health care services." It continued: "[Chicago HMO] 
warrants that it is able to provide the medical care and services required under 
this Agreement in accordance with prevailing community standards, and is able to 
provide these services promptly, efficiently, and economically."
Article V of the agreement described various duties of Chicago HMO, as 
follows. Chicago HMO "shall provide or arrange to have provided all covered 
services to all Beneficiaries under this Agreement." Chicago HMO "shall provide 
all Beneficiaries with medical care consistent with prevailing community 
standards." In addition, a section entitled "Choice of Physicians" provided in 
relevant part:
Another article V duty stated that, although Chicago HMO may furnish the 
services required by the agreement by means of subcontractors, Chicago HMO 
"shall remain responsible for the performance of the subcontractors."
Regarding appointments, this agreement stated that Chicago HMO "shall 
encourage members to be seen by appointment, except in emergencies." The 
agreement also stated that "[m]embers with more serious or urgent problems not 
deemed emergencies shall be triaged and provided same day service, if 
necessary," and that "emergency treatment shall be available on an immediate 
basis, seven days a week, 24-hours a day." Finally, the agreement directed that 
Chicago HMO "shall have an established policy that scheduled patients shall not 
routinely wait for more than one hour to be seen by a provider and no more than 
six appointments shall be made for each primary care physician per hour."
The record also contains a second agreement, a 1990 "MEDICAL GROUP SERVICE 
AGREEMENT" between Chicago HMO and Dr. Jordan, that lists a Chicago Heights 
office address for Dr. Jordan. This agreement described numerous duties of Dr. 
Jordan. Pertinent here, Dr. Jordan would provide to Chicago HMO subscribers 
specified medical services "of good quality and in accordance with accepted 
medical and hospital standards of the community." Pursuant to a "PUBLIC AID 
AMENDMENT TO THE MEDICAL GROUP SERVICE AGREEMENT," Dr. Jordan agreed to "abide 
by any conditions imposed by [Chicago HMO] as part of [Chicago HMO's] agreement 
with [the Department]."
The third agreement appearing of record is a second "MEDICAL GROUP SERVICE 
AGREEMENT" between Chicago HMO and Dr. Jordan. This agreement was entered into 
in 1987 and lists a Homewood office address for Dr. Jordan.
Both agreements between Chicago HMO and Dr. Jordan provided for a capitation 
method of compensation. Under capitation, Chicago HMO paid Dr. Jordan a fixed 
amount of money for each member who selected Dr. Jordan as the member's primary 
care provider. In exchange, Dr. Jordan agreed to render health care to his 
enrolled Chicago HMO members in accordance with the Chicago HMO health plan. Dr. 
Jordan was paid the same monthly capitation fee per member regardless of the 
services he rendered. For example, for each female patient under two years old, 
Chicago HMO paid Dr. Jordan $34.19 per month regardless of whether he treated 
that patient. In addition, Chicago HMO utilized an incentive fund for Dr. 
Jordan. Certain costs such as inpatient hospital costs were paid from this fund. 
Chicago HMO would then pay Dr. Jordan 60% of any remaining, unused balance of 
the fund at the end of each year.
As earlier noted, the appellate court affirmed the circuit court's grant of 
summary judgment in favor of Chicago HMO as to count I, institutional 
negligence, and as to count III, breach of contract. 301 Ill. App. 3d 103. We 
are asked to decide whether Chicago HMO was properly awarded summary judgment on 
these two counts.
ANALYSIS
We conduct de novo review of an award of summary judgment. Olson 
v. Etheridge, 177 Ill. 2d 396, 404 (1997). Summary judgment is proper where 
the pleadings, depositions, admissions, affidavits and exhibits on file, when 
viewed in the light most favorable to the nonmoving party, show that there is no 
genuine issue as to any material fact and that the moving party is entitled to 
judgment as a matter of law. Busch v. Graphic Color Corp., 169 Ill. 2d 325, 333 (1996). Summary judgment is a drastic remedy and should be allowed only 
when the right of the moving party is clear and free from doubt. Colvin v. 
Hobart Brothers, 156 Ill. 2d 166, 169-70 (1993).
This court first addressed a question of whether an HMO could be held liable 
for medical malpractice in Petrovich v. Share Health Plan of Illinois, 
Inc., 188 Ill. 2d 17, 29 (1999). Petrovich, however, involved 
different legal theories of liability than those presented here. 
Petrovich held that an HMO may be held vicariously liable for the 
medical malpractice of its independent-contractor physicians under both the 
doctrines of apparent authority and implied authority. Petrovich, 188 Ill. 2d 17. In contrast, this appeal focuses on whether an HMO may be held 
liable under the theory of institutional negligence.
I. Institutional Negligence
Institutional negligence is also known as direct corporate negligence. Since 
the landmark decision of Darling v. Charleston Community Memorial 
Hospital, 33 Ill. 2d 326 (1965), Illinois has recognized that 
hospitals may be held liable for institutional negligence. 
Darling acknowledged an independent duty of hospitals to assume 
responsibility for the care of their patients. Ordinarily, this duty is 
administrative or managerial in character. Advincula v. United Blood 
Services, 176 Ill. 2d 1, 28 (1996) (and authorities cited therein). To 
fulfill this duty, a hospital must act as would a "reasonably careful hospital" 
under the circumstances. Advincula, 176 Ill. 2d  at 29. Liability is 
predicated on the hospital's own negligence, not the negligence of the 
physician.
Underlying the tort of institutional negligence is a recognition of the 
comprehensive nature of hospital operations today. The hospital's expanded role 
in providing health care services to patients brings with it increased corporate 
responsibilities. As Darling explained: "Present-day hospitals, as 
their manner of operation plainly demonstrates, do far more than furnish 
facilities for treatment. They regularly employ on a salary basis a large staff 
of physicians, nurses and internes, as well as administrative and manual 
workers, and they charge patients for medical care and treatment, collecting for 
such services, if necessary, by legal action." Darling, 33 Ill. 2d  at 
332. Expounding on the point, this court later stated: "[A] modern hospital *** 
is an amalgam of many individuals not all of whom are licensed medical 
practitioners. Moreover, it is clear that at times a hospital functions far 
beyond the narrow sphere of medical practice." Greenberg v. Michael Reese 
Hospital, 83 Ill. 2d 282, 293 (1980). Thus, in recognizing hospital 
institutional negligence as a cause of action, Darling merely applied 
principles of common law negligence to hospitals in a manner that comports with 
the true scope of their operations. See Darling, 33 Ill. 2d  at 331 
(noting that the duty in negligence cases is always the same, to conform to the 
legal standard of reasonable conduct in light of the apparent risk).
In accordance with the preceding rationale, we now hold that the doctrine of 
institutional negligence may be applied to HMOs. This court in Petrovich 
acknowledged the potential for applying this theory to HMOs. See 
Petrovich, 188 Ill. 2d  at 30 (and authorities cited therein). A court 
in another jurisdiction has likewise extended the theory of hospital 
institutional negligence to HMOs. Shannon v. McNulty, 718 A.2d 828 (Pa. 
Super. Ct. 1998). It did so out of a recognition that HMOs, like hospitals, 
consist of an amalgam of many individuals who play various roles in order to 
provide comprehensive health care services to their members. Shannon, 
718 A.2d  at 835-36. Moreover, because HMOs undertake an expansive role in 
arranging for and providing health care services to their members, they have 
corresponding corporate responsibilities as well. Shannon, 718 A.2d at 
835-36; see Petrovich, 188 Ill. 2d  at 28, 33-40 (recognizing that HMOs 
act as health care providers and attempt to contain the costs of health care); 
215 ILCS 125/1-2(9) (West 1998) (defining an HMO as "any organization formed *** 
to provide or arrange for one or more health care plans under a system which 
causes any part of the risk of health care delivery to be borne by the 
organization or its providers"); Official Lists Current Amicus Briefs of 
Labor Department on Medical Malpractice, 68 U.S.L.W. 2249-50 (November 2, 
1999) (noting that, according to the United States Department of Labor, HMOs 
wear "three different hats," one of which is "medical provider"). Our nationwide 
research has revealed no decision expressing a contrary view, and Chicago HMO 
makes no argument against extending the doctrine of institutional negligence to 
HMOs. Hence, we conclude that the law imposes a duty upon HMOs to conform to the 
legal standard of reasonable conduct in light of the apparent risk. See 
Darling, 33 Ill. 2d  at 331. To fulfill this duty, an HMO must act as 
would a "reasonably careful" HMO under the circumstances. See 
Advincula, 176 Ill. 2d  at 29.
Having determined that institutional negligence is a valid claim against 
HMOs, we turn to the parties' arguments in this case. Jones contends that 
Chicago HMO is not entitled to summary judgment on her claim of institutional 
negligence. She asserts that genuine issues of material fact exist as to whether 
Chicago HMO (1) negligently assigned more enrollees to Dr. Jordan than he was 
capable of serving, and (2) negligently adopted procedures requiring Jones to 
call first for an appointment before visiting the doctor's office.
Chicago HMO argues that Jones' claim of institutional negligence cannot 
proceed because she failed to provide sufficient evidence delineating the 
standard of care required of an HMO in these circumstances. In particular, 
Chicago HMO contends that Jones should have presented expert testimony on the 
standard of care required of an HMO.
Jones responds that she has provided sufficient evidence showing the standard 
of care required of an HMO in these circumstances. She argues further that her 
claim does not require expert testimony on this point. In support, Jones relies 
on Darling, where a claim of institutional negligence was allowed 
against a hospital without expert testimony because other evidence established 
the hospital's standard of care. Darling, 33 Ill. 2d 326.
Given that the parties' dispute centers on standard of care evidence and the 
need for expert testimony, we briefly review the roles of the standard of care 
and expert testimony in negligence cases. We then discuss Darling and 
its progeny.
The elements of a negligence cause of action are a duty owed by the defendant 
to the plaintiff, a breach of that duty, and an injury proximately caused by the 
breach. Cunis v. Brennan, 56 Ill. 2d 372, 374 (1974). The standard of 
care, also known as the standard of conduct, falls within the duty element. Dean 
Prosser has explained:
In an ordinary negligence case, the standard of care required of a defendant 
is to act as would an " 'ordinarily careful person' " or a 
" 'reasonably prudent' person." Advincula v. United Blood 
Services, 176 Ill. 2d 1, 22 (1996), quoting Cunis, 56 Ill. 2d  at 
376. No expert testimony is required in a case of ordinary negligence. See 
Advincula,176 Ill. 2d  at 24.
In contrast, in a professional negligence case, the standard of care required 
of a defendant is to act as would an "ordinarily careful professional." 
Advincula, 176 Ill. 2d  at 23. Pursuant to this standard of care, 
professionals are expected to use the same degree of knowledge, skill and 
ability as an ordinarily careful professional would exercise under similar 
circumstances. Advincula, 176 Ill. 2d  at 23-24. Expert testimony is 
usually required in a case of professional negligence. Advincula, 176 Ill. 2d  at 24, 38. Expert testimony is necessary to establish both (1) the 
standard of care expected of the professional and (2) the professional's 
deviation from the standard. See Purtill v. Hess, 111 Ill. 2d 229, 242 
(1986). The rationale for requiring expert testimony is that a lay juror is not 
skilled in the profession and thus is not equipped to determine what constitutes 
reasonable care in professional conduct without the help of expert testimony. 
Advincula, 176 Ill. 2d  at 24; see Purtill, 111 Ill. 2d  at 246. 
In Illinois, a professional standard of care has been applied in cases involving 
a variety of both medical and nonmedical professions, such as law and dentistry. 
Advincula, 176 Ill. 2d  at 23-24 (and cases cited therein).
The foregoing principles of law establish that the crucial difference between 
ordinary negligence and professional malpractice actions is the necessity of 
expert testimony to establish the standard of care and that its breach was the 
cause of the plaintiff's injury. Although not applicable to this case, there are 
exceptions to the requirement of expert testimony in professional negligence 
cases. For example, in instances where the professional's conduct is so grossly 
negligent or the treatment so common that a lay juror could readily appraise it, 
no expert testimony or other such relevant evidence is required. 
Advincula, 176 Ill. 2d  at 24 (and cases cited therein); Walski v. 
Tiesenga, 72 Ill. 2d 249, 257 (1978) (noting that examples of this 
exception in medical malpractice cases include instruments left in a patient's 
body after surgery and X-ray burns); see also Ohligschlager v. Proctor 
Community Hospital, 55 Ill. 2d 411 (1973) (holding that a drug 
manufacturer's instructions provided the proper standard of care with which to 
measure the conduct of a physician).
As Jones correctly notes, the institutional negligence of hospitals can also 
be determined without expert testimony in some cases. The standard of care 
evidence required to bring an action for institutional negligence against a 
hospital is best understood by a review of the relevant case law.
In Darling v. Charleston Community Memorial Hospital, 33 Ill. 2d 326 
(1965), the plaintiff had his leg placed in a cast at the defendant hospital. 
While remaining at the hospital, he suffered a serious case of gangrene. He 
ultimately lost his leg below the knee. The plaintiff brought an action directly 
against the hospital for failing to have trained nurses monitor his condition 
and for failing to review his treatment. In support of his argument that the 
hospital breached the standard of care required of hospitals in this regard, the 
plaintiff presented evidence that the hospital breached its own bylaws, as well 
as the state's licensing regulations and the "Standards for Hospital 
Accreditation." Darling, 33 Ill. 2d  at 330-32. A jury returned a 
verdict for the plaintiff, and this court affirmed. Darling, 33 Ill. 2d  
at 328.
As earlier noted, this court in Darling recognized an independent 
duty of hospitals to assume responsibility for the care of their patients. 
Relevant here, Darling also held that the hospital bylaws, licensing 
regulations, and standards for hospital accreditation were sufficient evidence 
with which to establish the hospital's standard of care. Darling 
likened this evidence to evidence of custom, which may also be used to determine 
a hospital's standard of care. The jury was therefore entitled to conclude from 
the plaintiff's evidence that the hospital had breached its duty to the 
plaintiff. Darling, 33 Ill. 2d  at 330-33.
In Greenberg v. Michael Reese Hospital, 83 Ill. 2d 282 (1980), a 
group of plaintiffs sued the hospital for injuries that they sustained as a 
result of being X-rayed without a protective shield. As standard of care 
evidence, the plaintiffs presented an expert witness who was a health physicist 
specializing in the effects of radiation. The hospital challenged the 
qualifications of plaintiffs' expert, claiming that, since he was not a 
physician practicing in any school of medicine, he could not testify concerning 
conduct that involves a medical judgment. This court held that the affidavit of 
the plaintiffs' nonphysician expert was sufficient to withstand the hospital's 
motion for summary judgment. Greenberg, 83 Ill. 2d  at 293-94. Although 
the expert was not a medical practitioner, he was highly qualified and familiar 
with radiation therapy in hospitals. This court deemed "it appropriate to the 
diversity inherent in hospital administration that a broad range of evidence be 
available to establish the applicable standard of care." Greenberg, 83 Ill. 2d  at 293.
More recently, this court in Advincula v. United Blood Services, 176 Ill. 2d 1, 29 (1996), stated that the standard of care required of a hospital in 
a case of institutional negligence may be shown by a wide variety of evidence, 
including, but not limited to, expert testimony, hospital bylaws, statutes, 
accreditation standards, custom and community practice. Advincula 
explained that this variety of evidence is appropriate given the inherent 
diversity in hospital administrative and managerial actions, only a portion of 
which involves the exercise of medical judgment. Advincula, 176 Ill. 2d  
at 32-34. Advincula further explained, however, that the tort of 
institutional negligence "does not encompass, whatsoever, a hospital's 
responsibility for the conduct of its *** medical professionals." 
Advincula, 176 Ill. 2d  at 31. Rather, in cases against hospitals based 
on vicarious liability for the conduct of medical professionals, the standard of 
care remains the standard applied to all professionals, i.e., to use 
the same degree of knowledge, skill and ability as an ordinarily careful 
professional would exercise under similar circumstances. Advincula, 176 Ill. 2d  at 30, 31.
Darling and its progeny have firmly established that, in an action 
for institutional negligence against a hospital, the standard of care applicable 
to a hospital may be proved via a number of evidentiary sources, and expert 
testimony is not always required. Advincula, 176 Ill. 2d at 29-34; 
Greenberg, 83 Ill. 2d at 293-94; Darling, 33 Ill. 2d  at 
330-33. We likewise conclude that, in an action for institutional negligence 
against an HMO, the standard of care applicable to an HMO may be proved through 
a number of evidentiary sources, and expert testimony is not necessarily 
required. Accordingly, expert testimony concerning the standard of care required 
of an HMO is not a prerequisite to Jones' claim. Nonetheless, Jones, as the 
plaintiff here, still bears the burden of establishing the standard of care 
required of an HMO through other, proper evidentiary sources. We must therefore 
evaluate the evidence presented on this point to determine whether Jones' claim 
withstands Chicago HMO's motion for summary judgment. In deciding whether Jones' 
standard of care evidence is sufficient, we look to whether that evidence can 
equip a lay juror to determine what constitutes the standard of care required of 
a "reasonably careful HMO" under the circumstances of this case.
A. Patient Load
We first consider Jones' assertion that Chicago HMO negligently assigned more 
patients to Dr. Jordan than he was capable of serving. Parenthetically, we note 
that this assertion involves an administrative or managerial action by Chicago 
HMO, not the professional conduct of its physicians. Therefore, this claim 
properly falls within the purview of HMO institutional negligence. Jones argues 
that the standard of care evidence in the record is sufficient to support her 
claim. She points to Dr. Trubitt's testimony, as well as the contract between 
Chicago HMO and the Department of Public Aid.
Dr. Trubitt was the medical director for Chicago HMO. He testified that, when 
Chicago HMO entered into agreements with primary care physicians, it considered 
the number of patients that the physician is capable of handling. The HMO would 
look to federal "guidelines" in making this determination. Based on those 
guidelines, Dr. Trubitt expressed 3,500 as the maximum number of patients that 
should be assigned to any one primary care physician. He stated that, if Dr. 
Jordan himself had 6,000 or more patients, then that would be an unusually large 
number and of concern to Chicago HMO.
We agree with Jones that Dr. Trubitt's testimony is proper and sufficient 
evidence of the standard of care on this issue. According to Dr. Trubitt, an HMO 
should not assign more than 3,500 patients to any single primary care physician. 
Chicago HMO even concedes in its brief that the maximum patient load to which 
Dr. Trubitt testified "represent[s] a 'standard of care' whose violation could 
affect the quality of patient care." This particular standard of care evidence, 
setting forth a limit of 3,500 patients per primary care physician, is adequate 
to equip a lay juror to determine what constitutes the standard of care required 
of a "reasonably careful HMO" under the circumstances of this case. Whether Dr. 
Trubitt relied on an unidentified federal regulation or some other source in 
arriving at a maximum patient load of 3,500 is of no consequence. It is enough 
that Chicago HMO, through its medical director, admitted that it used the 3,500 
limit as a guide in assigning patient loads. See Darling, 33 Ill. 2d  at 
330-33 (holding that the hospital's own bylaws may be used to establish the 
hospital's standard of care).
Chicago HMO, however, submits that there is no evidence in the record that 
Dr. Jordan's patient load exceeded 3,500. We disagree. Chicago HMO's "Provider 
Capitation Summary Reports" listed Dr. Jordan as being the primary care provider 
of 4,527 Chicago HMO members as of December 1, 1990. Thus, Chicago HMO's own 
records show Dr. Jordan's patient load as exceeding the 3,500 limit by more than 
1,000 patients. In addition, Dr. Jordan estimated that he himself was designated 
the primary care physician for an additional 1,500 members of other HMOs. He 
also maintained his own private practice of non-HMO patients. This evidence 
supports Jones' theory that Dr. Jordan had more than 6,000 HMO patients.
Chicago HMO, in support of its position, points to Dr. Jordan's testimony 
that he employed four part-time physicians in his office. We disagree with 
Chicago HMO concerning the significance of this testimony. Although Dr. Jordan 
testified that he employed four part-time physicians, he never explained in what 
capacities these physicians served. In fact, the record contains no further 
information regarding these physicians. Notably, the agreements between Chicago 
HMO and Dr. Jordan do not refer to any physicians other than Dr. Jordan himself. 
The evidence in the record, therefore, supports Jones' theory that Chicago HMO 
negligently assigned more than 3,500 patients to Dr. Jordan himself. At best, 
the testimony regarding the four part-time physicians creates a genuine issue of 
material fact as to how many patients Dr. Jordan actually served himself. 
Consequently, this limited information in the record about part-time physicians 
does not entitle Chicago HMO to summary judgment. As earlier noted, it is well 
established that summary judgment is a drastic remedy and should be awarded only 
where the right of the moving party is clear and free from doubt.
Chicago HMO also submits that Jones' claim of patient overload must fail 
because there is no evidence of a causal connection between the number of 
patients that Dr. Jordan was serving and his failure to schedule an appointment 
to see Shawndale. We disagree. We can easily infer from this record that Dr. 
Jordan's failure to see Shawndale resulted from an inability to serve an 
overloaded patient population. A lay juror can discern that a physician who has 
thousands more patients than he should will not have time to service them all in 
an appropriate manner.
We note, moreover, that additional evidence in the record supports Jones' 
claim. The record indicates that Chicago HMO was actively soliciting new members 
door-to-door around the same time that it lacked the physicians willing to serve 
those members. Jones described how she first enrolled in Chicago HMO while 
living in Park Forest. A Chicago HMO representative visited her home and 
persuaded her to become a member, telling her that Chicago HMO "is better than a 
regular medical card." When Jones later moved to Chicago Heights, another 
Chicago HMO representative visited her home. Jones explained that this meeting 
was not arranged in advance. Rather, the representative was "in the building 
knocking from door to door." Jones also testified that, when she moved to 
Chicago Heights, Chicago HMO assigned Dr. Jordan to her and did not give her a 
choice of primary care physicians.
The latter aspect of Jones' testimony was supported by Dr. Trubitt. He 
explained that, before Chicago HMO and Dr. Jordan executed the Chicago Heights 
service agreement, another physician serviced that area. When Chicago HMO 
terminated that other physician, Dr. Jordan agreed "to go into the [Chicago 
Heights] area and serve the patients." Chicago HMO then assigned to Dr. Jordan 
all of the patients of that physician. Chicago HMO directed its members to Dr. 
Jordan; they had no other choice of a physician because "[a]t that point in the 
area there was no choice." According to Dr. Trubitt, Dr. Jordan was Chicago 
HMO's only physician who was willing to serve the public aid membership in 
Chicago Heights. Dr. Trubitt stated that this lack of physicians was "a problem" 
for Chicago HMO.
The record further reflects that Chicago HMO directed its Chicago Heights 
members to Dr. Jordan, even though it knew that Dr. Jordan worked at that 
location only half the time. Chicago HMO entered into two service agreements 
with Dr. Jordan, the first for a Homewood site in 1987, and the second for the 
Chicago Heights site in 1990. Dr. Trubitt indicated that Chicago HMO and Dr. 
Jordan executed the Chicago Heights service agreement at the time that Chicago 
HMO terminated the other physician. Dr. Jordan confirmed that, in January of 
1991, he was dividing his time equally between his two offices. All of the 
foregoing evidence supports Jones' theory that Chicago HMO acted negligently in 
assigning more enrollees to Dr. Jordan than he was capable of handling.
Jones also relies on the contract between Chicago HMO and the Department of 
Public Aid as standard of care evidence. That contract stated that Chicago HMO 
shall have one full-time equivalent primary care physician for every 2,000 
enrollees. We need not address in this appeal whether this contractual provision 
may serve as standard of care evidence. Our role here is to determine whether 
Chicago HMO is entitled to summary judgment on the patient overload aspect of 
the institutional negligence claim. Even if this contractual provision is 
removed from consideration, Chicago HMO is not entitled to summary judgment. 
Accordingly, we express no opinion on whether this provision may properly serve 
as standard of care evidence.
One final matter with respect to patient load remains to be considered. 
Chicago HMO contends that imposing a duty on HMOs to ascertain how many patients 
their doctors are serving would be unreasonably burdensome. Chicago HMO asserts 
that only physicians, and not HMOs, should have the duty to determine if the 
physician has too many patients.
To determine whether a duty exists in a certain instance, a court considers 
the following factors: (1) the reasonable foreseeability of injury, (2) the 
likelihood of injury, (3) the magnitude of the burden of guarding against the 
injury, and (4) the consequences of placing that burden upon the defendant. 
Deibert v. Bauer Brothers Construction Co., 141 Ill. 2d 430, 437-38 
(1990); Kirk v. Michael Reese Hospital &amp; Medical Center, 117 Ill. 2d 507, 526 (1987). Lastly, the existence of a duty turns in large part on 
public policy considerations. Ward v. K mart Corp., 136 Ill. 2d 132, 
151 (1990); see Mieher v. Brown, 54 Ill. 2d 539, 545 (1973). Whether a 
duty exists is a question of law to be determined by the court. Cunis, 
56 Ill. 2d  at 374.
Here, given the circumstances of this case, we hold that Chicago HMO had a 
duty to its enrollees to refrain from assigning an excessive number of patients 
to Dr. Jordan. HMOs contract with primary care physicians in order to provide 
and arrange for medical care for their enrollees. It is thus reasonably 
foreseeable that assigning an excessive number of patients to a primary care 
physician could result in injury, as that care may not be provided. For the same 
reason, the likelihood of injury is great. Nor would imposing this duty on HMOs 
be overly burdensome. Here, for example, Chicago HMO needed only to review its 
"Provider Capitation Summary Reports" to obtain the number of patients that it 
had assigned to Dr. Jordan. This information is likely to be available to all 
HMOs, as they must know the number of patients that a physician is serving in 
order to compute the physician's monthly capitation payments. The HMO may also 
simply ask the physician how many patients the physician is serving. Finally, 
the remaining factors favor placing this burden on HMOs as well. Public policy 
would not be well served by allowing HMOs to assign an excessive number of 
patients to a primary care physician and then "wash their hands" of the matter. 
The central consequence of placing this burden on HMOs is HMO accountability for 
their own actions. This court in Petrovich recognized that HMO 
accountability is needed to counterbalance the HMO goal of cost containment and, 
where applicable, the inherent drive of an HMO to achieve profits. 
Petrovich, 188 Ill. 2d  at 29.
In conclusion, Chicago HMO is not entitled to summary judgment on Jones' 
claim of institutional negligence for assigning too many patients to Dr. 
Jordan.
B. Appointment Procedures
We next consider Jones' assertion that Chicago HMO negligently adopted 
procedures requiring Jones to call first for an appointment before visiting the 
doctor's office or obtaining emergency care. Jones fails to develop this 
argument in her brief. In particular, she points to no evidence in the record as 
providing the standard of care required of an HMO in developing appointment 
procedures. This claim cannot proceed without standard of care evidence. Chicago 
HMO is therefore entitled to summary judgment with respect to this portion of 
Jones' claim of institutional negligence.
II. Breach of Contract
Jones argues that Chicago HMO is not entitled to summary judgment on her 
breach of contract claim. This claim, set forth in count III of Jones' 
complaint, is based solely on the contract between Chicago HMO and the 
Department of Public Aid. Jones is not a signatory to this contract, but rather 
a beneficiary. Jones, however, expressly disclaims any reliance on a third-party 
beneficiary theory of liability. Instead, Jones insists that she may maintain an 
action for damages against Chicago HMO as if she were a party to the 
agreement.
The appellate court held that summary judgment was properly awarded to 
Chicago HMO on this claim because Jones is not a party to the contract at issue. 
The appellate court also noted that Jones' theory of liability in this regard 
was "murky at best." 301 Ill. App. 3d at 115.
We hold that Chicago HMO is entitled to summary judgment on count III. The 
record discloses that Jones is not a party to the contract that she seeks to 
enforce. Rather, the contracting parties are Chicago HMO and the Department. 
Nonetheless, Jones insists that she may maintain a cause of action on that 
contract, while also disclaiming any reliance on a third-party beneficiary 
theory of liability. Jones' position is not correct as a matter of law. See 
Olson v. Etheridge, 177 Ill. 2d 396, 404 (1997) (explaining third-party 
beneficiary theory); 17A Am. Jur. 2d Contracts §§ 435, 437 (2d ed. 
1991) (noting that a nonparty to a contract must sue under a third-party 
beneficiary theory). We also agree with the appellate court that the theory 
presented by Jones on this point is not clear.
III. Breach of Warranty
Jones lastly argues that she should be permitted to pursue a breach of 
warranty claim against Chicago HMO. She asserts that count III can be construed 
as raising this claim. Chicago HMO counters that Jones has waived any breach of 
warranty claim by failing to raise it in the courts below. We agree with Chicago 
HMO. Issues raised for the first time on appeal are waived. Employers 
Insurance v. Ehlco Liquidating Trust, 186 Ill. 2d 127, 161 (1999). Our 
review of the record reveals that Jones did not raise this claim in either the 
circuit court or the appellate court. Nor did Jones raise this issue in her 
petition for leave to appeal. We thus conclude that Jones has waived any claim 
of breach of warranty.
CONCLUSION
An HMO may be held liable for institutional negligence. Chicago HMO is not 
entitled to summary judgment on Jones' claim charging Chicago HMO with 
institutional negligence for assigning more enrollees to Dr. Jordan than he was 
capable of serving. We therefore reverse the award of summary judgment to 
Chicago HMO on count I of Jones' second amended complaint and remand that claim 
to the circuit court for further proceedings. As to count III, we affirm the 
award of summary judgment to Chicago HMO.
The judgments of the appellate and circuit courts are affirmed in part and 
reversed in part and the cause is remanded to the circuit court.
Judgments affirmed in part and reversed in part;
cause remanded.JUSTICE MILLER, concurring in part and 
dissenting in part:
I agree with the majority that the trial court properly granted the 
defendant's motion for summary judgment on count III of the plaintiff's second 
amended complaint, which alleges breach of contract. I do not agree with the 
majority's conclusion that summary judgment is not also appropriate on count I, 
which alleges institutional negligence.
The majority opinion correctly notes that the defendant makes no argument 
against extending the doctrine of institutional negligence to health maintenance 
organizations, such as the defendant. Slip op. at 12. In this regard, Justice 
Rathje's separate opinion would grant the defendant more extensive relief than 
the defendant itself requests, by ruling in its favor on an issue much broader 
than the one actually raised by the HMO, and for that reason I cannot join his 
partial concurrence and dissent. The defendant does argue, however, that summary 
judgment was proper on count I because there is no evidence of a causal 
connection between the number of patients assigned to Dr. Jordan by the 
defendant and the doctor's failure to schedule an immediate appointment to see 
the plaintiff's daughter.
Reaching a contrary conclusion, the majority accepts the plaintiff's 
assertion that a genuine issue of material fact exists regarding whether the 
number of patients assigned by the defendant to Dr. Jordan was a proximate cause 
of the plaintiff's injury. In support of this result, the majority states, "We 
can easily infer from this record that Dr. Jordan's failure to see Shawndale 
resulted from an inability to serve an overloaded patient population. A lay 
juror can discern that a physician who has thousands more patients than he 
should will not have time to service them all in an appropriate manner." Slip 
op. at 18-19.
The majority emphasizes Dr. Trubitt's deposition testimony, in which Dr. 
Trubitt stated that 6,000 to 6,500 patients would be an unusually large load for 
a doctor to carry. The majority ignores Dr. Trubitt's further testimony on this 
subject, however, in which he explained that the number of patients formally 
assigned to a particular doctor may be expanded, if there are additional doctors 
in the office and the hours of operation for the office are increased.
But even this testimony is insufficient to give rise to a genuine issue of 
material fact, for the plaintiff presents no support for the allegation that the 
injury was proximately caused by the number of patients assigned by the 
defendant to Dr. Jordan. As the trial judge reasoned in granting summary 
judgment to the defendant on this portion of the plaintiff's second amended 
complaint:
The appellate court made the same point, similarly noting the absence of any 
evidence in the record specifically linking the size of Dr. Jordan's patient 
load in January 1991 with the negligence alleged by the plaintiff, the failure 
to schedule an immediate appointment for her daughter. 301 Ill. App. 3d 103, 
111.
Whether Dr. Jordan and the other physicians in his practice together served 
1,000 patients, 3,000 patients, 5,000 patients, or more, the majority cites 
nothing in the record before us from which one may infer that Dr. Jordan's 
failure to schedule an immediate appointment to see the plaintiff's daughter on 
the day in question was the result of the number of patients assigned to and 
served by his office. I believe that summary judgment in the defendant's favor 
was proper on count I, and therefore I would affirm that portion of the judgment 
below.
JUSTICE RATHJE, also concurring in part and dissenting in part:
I agree with both the majority's affirmance of summary judgment on the breach 
of contract claim and its determination that plaintiff has waived the breach of 
warranty claim. I strongly disagree, however, with the majority's holding that 
Chicago HMO can be liable under a theory of institutional liability.
The majority reasons that, because an HMO is an "amalgam of many individuals" 
like a hospital, then Chicago HMO can be institutionally liable under the rule 
set forth in Darling v. Charleston Community Memorial Hospital, 33 Ill. 2d 326 (1965). Slip op. at 11-12. Although both a hospital and an HMO hire many 
different people for many different reasons, the reasons for holding hospitals 
liable under this theory do not hold true for Chicago HMO.
Generally, institutional liability attaches when an organization breaches a 
duty it owes as an organization.(1) Under 
Darling, hospitals are vulnerable to institutional liability partly 
because, as organizations, they offer complete medical services, including 
nurses, doctors, orderlies, and administration. Darling, 33 Ill. 2d  at 
332. Hospital facilities include both the place and the staff, and hospitals 
"assume certain responsibilities for the care of the patient." Darling, 
33 Ill. 2d  at 332. In Darling, the hospital was negligent for two 
reasons: it failed to properly review the work of an independent doctor, and its 
nurses failed to administer necessary tests. Darling, 33 Ill. 2d  at 
333. The rule set forth in Darling is that a hospital must act as a 
reasonably careful hospital would and is responsible for reviewing and 
supervising the medical care given to its patients. Advincula v. United 
Blood Services, 176 Ill. 2d 1, 28-29 (1996).
Shannon v. McNulty, 718 A.2d 828 (Pa. Super. 1998), the case upon 
which the majority relies, is perfectly consistent with the principles set forth 
in Darling and Avincula. In Shannon, the defendant 
HMO was not serving simply as a vehicle through which a member's medical bills 
are paid. Instead, the HMO employed nurses to work its own triage service and to 
advise members on medical decisions such as whether to seek treatment at a 
hospital. Shannon, 718 A.2d  at 832-33. The court concluded:
The passage demonstrates why Chicago HMO is not subject to institutional 
liability. Under Chicago HMO's contract with Dr. Jordan, Chicago HMO is 
responsible for enrolling members, providing the doctor's group with a current 
list of those members, paying capitation fees, providing a list of hospitals and 
health care providers, providing other funding, and obtaining the appropriate 
regulatory licensure for the doctor's group. The doctor's group is solely 
responsible for providing the health services. Moreover, Chicago HMO's member's 
handbook specifically explains that the individual doctors are responsible for 
nurses and all other medical attention. Unlike the HMO in Shannon, 
which "provid[ed] health care services," Chicago HMO "merely provid[ed] money to 
pay for services." Thus, institutional liability is inappropriate in this 
case.
The primary flaw in the majority's analysis is that it attempts to create a 
rule of general application that fails to take into account not only the 
differences that exist between a hospital and an HMO but also those that exist 
among HMOs. To determine whether an HMO should have the same duty to its members 
that a hospital has to its patients, a court must assess not only whether 
hospitals are similar to HMOs but also whether the patient's relationship to the 
hospital is similar to the member's relationship to the HMO. See Kirk v. 
Michael Reese Hospital &amp; Medical Center, 117 Ill. 2d 507, 525 (1987) 
(the question of whether a duty exists is "whether the defendant and the 
plaintiff stood in such a relationship to one another that the law imposed upon 
the defendant an obligation of reasonable conduct for the benefit of the 
plaintiff").
Hospitals are "institutions holding themselves out as devoted to the care and 
saving of human life." Johnson v. St. Bernard Hospital, 79 Ill. App. 3d 
709, 716 (1979). Institutional liability makes sense in the hospital context 
because a person in need of treatment must be assured that the hospital will 
abide by a sufficient standard of care. That patient generally does not have the 
time or opportunity to compare hospital bylaws or look for the hospital with the 
best administrative policies and the highest standard of care. A person goes to 
the nearest hospital in an emergency or to a hospital where his doctor has 
privileges in a nonemergency. In many cases, including most emergent cases, the 
patient has no time to make an informed choice. In his relationship with a 
hospital, the patient is at a severe disadvantage, which the law acknowledges by 
subjecting hospitals to institutional liability.
By contrast, the goal of an HMO is to provide health care in a cost-sensitive 
manner. B. Furrow, Managed Care Organizations and Patient Injury: Rethinking 
Liability, 31 Ga. L. Rev. 419, 457 (1997). HMOs offer medical services, but 
they do not do so in the same way that hospitals do. HMOs offer the funding and 
the contact with the medical professionals. In Chicago HMO, for instance, the 
way in which daily business is conducted, the duties of nurses and other staff, 
and other day-to-day decisions are made by the individual doctor or hospital 
with whom the HMO has contracted.(2) This 
type of HMO makes no decision as to what type of care is ultimately given; they 
only decide whether the HMO will pay for that care.
Moreover, when a person joins an HMO, he knows beforehand what that HMO will 
cover and, in most cases, chooses which HMO he will join based on his assessment 
of the costs and benefits. To become a member, that person usually has to 
contract with the HMO.(3) As a 
result, the HMO will be held accountable for any failure to comply with its own 
policies through a contract action.
In this case, the Chicago HMO representative arrived at plaintiff's door and 
asked her whether she would prefer to receive her public aid medical benefits 
through the HMO or continue receiving them directly through public aid. He 
reviewed the policies, and plaintiff made the decision to join, signing a 
statement that her participation in the HMO was voluntary and that she could 
disenroll at any time. Plaintiff was given the opportunity to make an informed 
choice and chose to receive her medical services through an HMO.
Just as hospitals can differ substantially from HMOs, substantial differences 
may exist among HMOs. Generally, HMOs are organized under one of four major 
models: (1) staff, in which the providers are all salaried employees of the HMO; 
(2) medical group, in which the HMO contracts with an organized group of doctors 
who have combined their practices; (3) independent practice association; in 
which the HMO contracts with individual physicians who are solo or group 
practitioners; and (4) network models, in which the HMO contracts with two or 
more physician group practices who may serve several HMOs at the same time. Both 
the methods of organization and the methods of reimbursement vary among the 
models. E. Weiner, Managed Health Care: HMO Corporate Liability, Independent 
Contractors, and the Ostensible Agency Doctrine, 15 J. Corp. L. 535, 540 
(1990). In some cases, an HMO may behave very much like a hospital, and 
institutional liability might be appropriate in such cases. In most cases, 
however, an HMO will do everything in its power not to behave like a 
hospital, precisely to avoid the liability that comes with operating as one. 
Having a uniform standard of care for all HMOs makes little sense, given the 
major differences in structure.
Before concluding, I wish to stress that I by no means believe that HMOs 
should not be held accountable for their actions. Ordinarily, an HMO will be 
accountable to its members through the contract that is signed by both parties. 
Unfortunately, in this case, plaintiff was receiving benefits from the HMO 
through public aid and, therefore, did not contract with the HMO. Consequently, 
as the majority correctly holds, her particular situation leaves her unable to 
enforce the policy provisions because she was not a party to the contract. Slip 
op. at 22. While I sympathize with plaintiff's unenviable position, the fact 
remains that plaintiff's theory of liability is not one permissible under our 
laws.
1. 1Contrast with vicarious liability, which 
attaches to an organization when one of its agents breaches his duty. 

2. 2Some HMOs do employ the staff and provide the 
facilities for care, but most do not. See E. Weiner, Managed Health Care: 
HMO Corporate Liability, Independent Contractors, and the Ostensible Agency 
Doctrine, 15 J. Corp. L. 535, 540 (1990). 

3. 3This case is an exception to that rule 
because the HMO membership was given to plaintiff by the Department of Public 
Aid. See slip op. at 22.