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November 03, 2003 at 07:00 PM
NU Online News Service, Nov. 3, 2003, 5:53 p.m. EST — Washington
The U.S. Supreme Court has agreed to decide whether managed care patients can sue their plans in state courts in connection with allegations of negligence arising from adverse medical necessity decisions.
At issue is whether state court actions against employer-sponsored health maintenance organizations are preempted by the Employee Retirement Income Security Act.
In two cases?Aetna v. Davila and CIGNA v. Calad?the 5th Circuit Court of Appeals ruled that ERISA does not preempt state law actions when HMOs make decisions that involve both eligibility and treatment.
Because ERISA does not preempt state law actions when HMOs make decisions that involve treatment, the patients in the two cases can sue their plans in state court for failure to use ordinary care in making decisions on medical necessity, the 5th Circuit ruled.
In one case, Ruby Calad, who was covered by a health plan run by a unit of CIGNA Corp., Philadelphia, underwent a hysterectomy. CIGNA allowed Calad a one-day hospital stay, which is standard, even though the attending physician recommended a longer stay.
Calad suffered complications and had to return to the hospital a few days later. She charged that the complications were caused by her early release.
In the other case, Juan Davila, who suffers from diabetes and arthritis, was covered by an Aetna managed care plan. His physician prescribed the medication Vioxx for Davila’s arthritis pain.
According to the 5th Circuit Court of Appeals, studies show that Vioxx has a lower rate of gastrointestinal toxicity than other drugs on Aetna’s formulary.
