The United States Supreme Court agreed today to hear two conflicting patient rights cases involving ERISA preemption of State Law where an HMO refuses to provide coverage or provides treatment different than that recommended by the patient's physician. The 1974 ERISA statute passed Congress long before the wide spread penetration of managed care in our health care system. The cases, Aetna Health Inc. v. Davila, 02-1845 and Cigna Healthcare of Texas Inc v. Caldad, 03-83, deal with the sticky question of whether a patient's sole recourse is to federal courts and limited to recovery of the service denied under ERISA.
The United States Supreme Court agreed today to hear two conflicting patient rights cases involving ERISA preemption of State Law where an HMO refuses to provide coverage or provides treatment different than that recommended by the patient's physician. The 1974 ERISA statute passed Congress long before the wide spread penetration of managed care in our health care system.
The cases, Aetna Health Inc. v. Davila, 02-1845 and Cigna Healthcare of Texas Inc v. Caldad, 03-83, deal with the sticky question of whether a patient's sole recourse is to federal courts and limited to recovery of the service denied under ERISA. ERISA does not permit money damages claims. In both cases the insurance companies moved to remove the cases the federal court and then moved to dismiss because of the lack of money damage jurisdiction.
Aetna denied Mr. Davila's right to a prescription for Vioxx and ended up with a cheaper prescription that caused him ulcers which almost lead to him bleeding to death. Ms. Calad could not obtain a recommended additional day in the hospital from Cigna and ended up having to be admitted to an emergency room several days later due to complications. The case will likely have wide ramifications as approximately 93 percent of employees with employer sponsored health plans are managed care enrollees.
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