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Supreme Court of the United States
January 16, 2002, Argued ; June 20, 2002, Decided
[**2156] [***385] [*359] JUSTICE SOUTER delivered the opinion of the Court.
Section 4-10 of Illinois's Health Maintenance Organization Act, 215 Ill. Comp. Stat., ch. 125, § 4-10 (2000), provides recipients of health coverage by such organizations with a right to independent medical review of certain denials of benefits. The issue in this case is whether the statute, as applied to health benefits provided by a health maintenance organization under contract with an employee welfare benefit [****9] plan, is preempted by the Employee Retirement Income Security Act of 1974 (ERISA), 88 Stat. 832, as amended, 29 U.S.C. § 1001 et seq. We hold it is not.
Petitioner, Rush Prudential HMO, Inc., is a health maintenance organization (HMO) that contracts to provide medical services for employee welfare benefit plans covered by ERISA. Respondent Debra Moran is a beneficiary under one such plan, sponsored by her husband's employer. Rush's "Certificate of Group Coverage," issued to employees who participate in employer-sponsored plans, promises that Rush will provide them with "medically necessary" services. The terms of the certificate give Rush the "broadest possible discretion" to determine whether a medical service claimed by a [*360] beneficiary is covered under the certificate. The certificate specifies that a service is covered as "medically necessary" if Rush finds:
"(a) [The service] is furnished or authorized by a Participating Doctor for the diagnosis or the treatment of a Sickness or Injury or for the maintenance of a person's good health.
"(b) The prevailing opinion within the appropriate specialty of the United States medical profession is that [the [****10] service] is safe and effective for its intended use, and that its omission would adversely affect the person's medical condition.
"(c) It is furnished by a provider with appropriate training, experience, staff and facilities to furnish that particular service or supply." Record, Plaintiff's Exh. A, p. 21.
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536 U.S. 355 *; 122 S. Ct. 2151 **; 153 L. Ed. 2d 375 ***; 2002 U.S. LEXIS 4644 ****; 70 U.S.L.W. 4600; 27 Employee Benefits Cas. (BNA) 2921; 15 Fla. L. Weekly Fed. S 409
RUSH PRUDENTIAL HMO, INC., PETITIONER v. DEBRA C. MORAN ET AL.
Prior History: [****1] ON WRIT OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE SEVENTH CIRCUIT.
Moran v. Rush Prudential HMO, Inc., 230 F.3d 959, 2000 U.S. App. LEXIS 26053, 25 Employee Benefits Cas. (BNA) 1667 (7th Cir. Ill. 2000)
Disposition: 230 F.3d 959, affirmed.
state law, benefits, insurers, arbitration, preemption, plans, pre-empted, medically necessary, regulate insurance, remedies, surgery, regulation, saving clause, coverage, provider, independent review, health maintenance organization, healthcare, managed care, employee benefit plan, remedial scheme, primary care physician, insurance regulation, contracts, reviewer, cause of action, Certificate, provisions, terms, terms of the contract
Civil Procedure, Appeals, Standards of Review, De Novo Review, Healthcare Law, Insurance Coverage, Health Insurance, Medical Necessity, Business & Corporate Compliance, Healthcare Law, Managed Healthcare, Health Maintenance Organizations, Public Health & Welfare Law, Healthcare, General Overview, Torts, Assumption of Risk, Elements & Nature, Primary Assumption of Risk, Insurance Law, Federal Regulations, ERISA, Pensions & Benefits Law, Federal Preemption, Savings Clause, Employee Benefit Plans, Federal Preemption, State Laws, Constitutional Law, Supremacy Clause, Industry Practices, Savings Clause, Business of Insurance Test, Contract Formation, Entities Within the Industry, Preemption Clause, Governments, Fiduciaries, Claim Procedures, Civil Litigation, Causes of Action, Fiduciaries, Named Fiduciary Appointment & Obligations, Judicial Review