Aetna Health, Inc. v. Davila

PETITIONER: Aetna Health Inc., fka Aetna U.S. Healthcare Inc. and Aetna U.S. Healthcare of North Texas Inc.
RESPONDENT: Ruby R. Calad, et al.
LOCATION: Guantanamo Bay, Cuba

DOCKET NO.: 02-1845
DECIDED BY: Rehnquist Court (1986-2005)
LOWER COURT: United States Court of Appeals for the Fifth Circuit

CITATION: 542 US 200 (2004)
GRANTED: Nov 03, 2003
ARGUED: Mar 23, 2004
DECIDED: Jun 21, 2004

ADVOCATES:
David C. Mattax - argued the cause for Respondents
David Mattax - for the State of Texas et al. as amici curiae urging affirmance
George Parker Young - argued the cause for Respondents
James A. Feldman - argued the cause for Petitioners, on behalf of the United States, as amicus curiae
Miguel A. Estrada - argued the cause for Petitioners

Facts of the case

Juan Davila sued his HMO in state court because it had refused to provide certain procedures, and the refusal led to certain injuries. He brought the suit under a Texas law that requires HMOs "to exercise ordinary care" for their patients. The HMO asked that the case be moved to federal court, arguing that the case should be governed under the Employee Retirement Income Security Act of 1974 (ERISA) rather than the Texas law, because ERISA is a federal law the takes precedence over any state laws dealing with the same subject matter. Davila objected, arguing that the case did not fall under ERISA and should be heard in state court. The federal district court sided with the HMO, finding that ERISA prohibits individuals from filing state suits against HMOs when they refuse to pay for a particular treatment. A Fifth Circuit Court of Appeals panel reversed.

Question

Does the Employee Retirement Income Security Act of 1974 prohibit individuals from suing their HMOs in state court when the HMOs refuse to provide a recommended treatment?

Media for Aetna Health, Inc. v. Davila

Audio Transcription for Oral Argument - March 23, 2004 in Aetna Health, Inc. v. Davila

Audio Transcription for Opinion Announcement - June 21, 2004 in Aetna Health, Inc. v. Davila

William H. Rehnquist:

The opinion of the Court in two cases will be announced by Justice Thomas.

Clarence Thomas:

The first opinions I have to announce are Aetna Health, Inc. versus Davila, No. 02-1845 and CIGNA Healthcare of Texas, Inc. versus Calad, No. 03-83.

These consolidated cases come to us on a writ of certiorari to the United States Court of Appeals for the Fifth Circuit.

Respondents are participants in a beneficiary in two separate ERISA-regulated employee health plans which are administered in part by petitioners.

Respondents allegedly suffered injuries caused by petitioner’s denials of coverage for certain medical treatments.

Respondents then sued petitioners in State Court under the Texas Healthcare Liability Act.

The Act refer to claiming that the denials of coverage violated petitioner’s duty under the Act to exercise ordinary care.

Petitioners removed the cases to Federal District Court arguing that the causes of action were completely preempted by the civil enforcement provision found at Section 502(a) of the Employee Retirement Income Security Act of 1974, ERISA.

Although the District Courts agreed with petitioners, on appeal, the Court of Appeals reversed.

It determined that respondents brought tort claims not breach of contract claims, sought remedies other than the payment of benefits, and sued for violation of a legal duty supposedly independent of those created by ERISA or the terms of the benefit plans.

Based on these factors, the Court of Appeals concluded that respondents’ causes of action did not duplicate any cause of action created by ERISA Section 502(a), and hence the causes of action were not completely preempted.

In an opinion filed with the Clerk today, we reverse the judgment of the Court of Appeals.

A state cause of action is completely preempted and hence, removable when the cause of action falls within the scope of the ERISA civil enforcement provision.

Respondents’ causes of action fall within the scope of ERISA 502(a)(1)(B) which provides a remedy for a wrongful denial of benefit.

The only injuries of which respondents’ complain are petitioners’ refusal to pay for medical treatment allegedly covered under the terms of ERISA-regulated employee benefit plans.

Respondents could have, upon learning of the denial of coverage, brought an action under ERISA 502(a)(1)(B).

Nor is an independent legal duty implicated here.

The Act expressly limits its scope to wrongful coverage decision.

Thus, interpretation of the terms of the plans is essential to respondents’ claims and any duties arising from the Act are inextricably intertwined with the rights and responsibilities set forth by ERISA and the plan terms.

Under these circumstances, the state causes of actions are deplicative of ERISA 502(a)(1)(B) and are hence, completely preempted.

Neither the Insurance Savings Clause found in ERISA 514(b)(2)(A), nor this Court’s opinion in Pegram versus Herdrich alter this conclusion.

The Insurance Savings Clause is not implicated where a state law creates a cause of action that duplicates or supplements the ERISA civil enforcement provision.

Pegram is implicated only where a person is acting as a treating position and as a benefit’s administrator simultaneously.

The mere fact that an eligibility determination is infused with medical judgment does not render anything other than an ordinary eligibility determination.

Thus, petitioners are not respondents' treating positions or employers are respondents' treating position, Pegram is not relevant here.

The opinion of the Court is unanimous.

Justice Ginsburg has filed a concurring opinion in which Justice Breyer has joined.