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Aetna Health Inc. v. Davila

Supreme Court of the United States

March 23, 2004, Argued ; June 21, 2004, Decided 1

No. 02-1845, No. 03-83

Opinion

 [*204]  [**2492]   Justice Thomas delivered the opinion of the Court.

In these consolidated cases, two individuals sued their respective health maintenance organizations (HMOs) for alleged failures to exercise ordinary care in the handling of coverage decisions, in violation of a duty imposed by the Texas Health Care Liability Act (THCLA), Tex. Civ. Prac. & Rem. Code Ann. §§ 88.001-88.003 (West 2004 Supp. Pamphlet). We granted certiorari to decide whether the individuals' causes of action are completely pre-empted by the "interlocking, interrelated, and interdependent remedial scheme,"  [**2493]   Massachusetts Mut. Life Ins. Co. v. Russell, 473 U.S. 134, 146, 87 L. Ed. 2d 96, 105 S. Ct. 3085 (1985), found at § 502(a) of the Employee Retirement Income Security Act of 1974 (ERISA), 88 Stat 891, as amended, 29 U.S.C. § 1132(a) et seq. [29 USCS §§ 1132(a) et seq.]. 540 U.S. 981, 540 U.S. 981, 157 L. Ed. 2d 370, 124 S. Ct. 462 (2003) . We hold that the causes of action are completely pre-empted and hence removable from state to federal court. The Court of Appeals, having [****8]  reached a contrary conclusion, is reversed.

Respondent Juan Davila is a participant, and respondent Ruby Calad is a beneficiary, in ERISA-regulated employee benefit plans. Their respective plan sponsors had entered into agreements with petitioners, Aetna Health Inc. and CIGNA HealthCare of Texas, Inc., to administer the plans. Under Davila's plan, for instance, Aetna reviews requests for coverage and pays providers, such as doctors, hospitals, and nursing homes, which perform covered services for members; under Calad's plan sponsor's agreement, CIGNA is responsible for plan benefits and coverage decisions.

Respondents both suffered injuries allegedly arising from Aetna's and CIGNA's decisions not to provide coverage for  [*205]  certain treatment and services recommended by respondents' treating physicians. Davila's treating physician prescribed Vioxx to remedy Davila's arthritis pain, but Aetna refused to pay for it. Davila did not appeal or contest this decision, nor did he purchase Vioxx with his own resources and seek reimbursement. Instead, Davila began taking Naprosyn, from which he allegedly  [***325]  suffered a severe reaction that required extensive treatment and hospitalization. Calad [****9]  underwent surgery, and although her treating physician recommended an extended hospital stay, a CIGNA discharge nurse determined that Calad did not meet the plan's criteria for a continued hospital stay. CIGNA consequently denied coverage for the extended hospital stay. Calad experienced postsurgery complications forcing her to return to the hospital. She alleges that these complications would not have occurred had CIGNA approved coverage for a longer hospital stay.

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542 U.S. 200 *; 124 S. Ct. 2488 **; 159 L. Ed. 2d 312 ***; 2004 U.S. LEXIS 4571 ****; 72 U.S.L.W. 4516; 32 Employee Benefits Cas. (BNA) 2569; 17 Fla. L. Weekly Fed. S 415

AETNA HEALTH INC., fka AETNA U.S. HEALTHCARE INC. and AETNA U.S. HEALTHCARE OF NORTH TEXAS INC., Petitioner v. JUAN DAVILA; CIGNA HEALTHCARE OF TEXAS, INC., dba CIGNA CORPORATION, Petitioner v. RUBY R. CALAD et al.

Prior History:  [****1] ON WRITS OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE FIFTH CIRCUIT.

Roark v. Humana, Inc., 307 F.3d 298, 2002 U.S. App. LEXIS 19139 (5th Cir. Tex., 2002)

Disposition: Reversed and remanded.

CORE TERMS

benefits, pre-empted, cause of action, fiduciary, respondents', coverage, decisions, cases, employee benefit plan, damages, terms, state cause of action, treating physician, remedies, civil enforcement, determinations, plans, district court, ordinary care, eligibility, pre-emption, entity, benefit plan, state law, pre-emptive, terms of the plan, federal court, discretionary, regulations, equitable

Civil Procedure, Removal, Specific Cases Removed, General Overview, Constitutional Law, Jurisdiction, Subject Matter Jurisdiction, Federal Questions, Federal Questions, Jurisdiction Over Actions, Preliminary Considerations, The Judiciary, Governments, Federal Government, Claims By & Against, Pensions & Benefits Law, ERISA, Federal Preemption, Employees & Officials, Civil Litigation, Federal Jurisdiction & Removal, Federal Preemption, Employee Benefit Plans, Civil Litigation, Business & Corporate Compliance, Funding Requirements, Pension Plan Funding, Labor & Employment Law, Collective Bargaining & Labor Relations, Causes of Action, Suits to Recover Plan Benefits, Remedies, Equitable Relief, Declaratory Judgments, Appeals, Standards of Review, De Novo Review, Fiduciaries, Welfare Benefit Plans, Healthcare Law, Managed Healthcare, Torts, Elements, Causation, Proximate Cause, Duty, Healthcare Law, Health Maintenance Organizations, Contracts Law, Breach, Procedural Matters, Preemption, Commercial Law (UCC), Sales (Article 2), Form, Formation & Readjustment, Pain & Suffering, Emotional Distress, Courts, Judicial Precedent, Damages, Punitive Damages, State Laws, Insurance Law, Industry Practices, Federal Regulations, Fiduciaries, Real Property Law, Trusts, Holding Trusts, Claim Procedures