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Keywords

liabilityrespondent

Related Cases

Aetna Health Inc. v. Davila, 542 U.S. 200, 124 S.Ct. 2488, 159 L.Ed.2d 312, 72 USLW 4516, 32 Employee Benefits Cas. 2569, Med & Med GD (CCH) P 301,496, 04 Cal. Daily Op. Serv. 5373, Pens. Plan Guide (CCH) P 23988K, 17 Fla. L. Weekly Fed. S 415

Facts

Respondents Juan Davila and Ruby Calad, participants and beneficiaries in ERISA-regulated employee benefit plans, alleged that their HMOs, Aetna and CIGNA, denied coverage for treatments recommended by their physicians. Davila was prescribed Vioxx for arthritis pain, which Aetna refused to cover, leading to severe complications from an alternative medication. Calad's extended hospital stay was denied by CIGNA, resulting in postsurgery complications. They sued in Texas state court under the THCLA, claiming the HMOs failed to exercise ordinary care in their coverage decisions.

Respondents both suffered injuries allegedly arising from Aetna's and CIGNA's decisions not to provide coverage for certain treatment and services recommended by respondents' treating physicians.

Issue

Are the respondents' state law claims under the Texas Health Care Liability Act completely preempted by the Employee Retirement Income Security Act (ERISA)?

We granted certiorari to decide whether the individuals' causes of action are completely pre-empted by the 'interlocking, interrelated, and interdependent remedial scheme,' found at § 502(a) of the Employee Retirement Income Security Act of 1974 (ERISA).

Rule

ERISA completely preempts state law claims that duplicate, supplement, or supplant its civil enforcement remedies, particularly those under ERISA § 502(a)(1)(B).

Any state-law cause of action that duplicates, supplements, or supplants ERISA's civil enforcement remedy conflicts with clear congressional intent to make that remedy exclusive, and is therefore pre-empted.

Analysis

The Supreme Court analyzed whether the respondents' claims arose under ERISA. It concluded that the claims were fundamentally about the denial of benefits under ERISA-regulated plans, and thus fell within the scope of ERISA § 502(a)(1)(B). The Court emphasized that the THCLA's duty of ordinary care was not independent of the ERISA plan terms, as the managed care entities could not be liable under the THCLA if the treatment was not covered by the plans they administered.

Thus, interpretation of the terms of respondents' benefit plans forms an essential part of their THCLA claim, and THCLA liability would exist here only because of petitioners' administration of ERISA-regulated benefit plans.

Conclusion

The Supreme Court reversed the Fifth Circuit's decision, holding that the respondents' state causes of action were completely preempted by ERISA and thus removable to federal court.

We hold that respondents' state causes of action fall 'within the scope of' ERISA § 502(a)(1)(B), and are therefore completely pre-empted by ERISA § 502 and removable to federal district court.

Who won?

The petitioners (Aetna and CIGNA) prevailed because the Supreme Court found that the respondents' claims were preempted by ERISA, allowing the cases to be removed to federal court.

The Supreme Court held that the THCLA claims were completely preempted by ERISA.

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