The United States Supreme Court earlier this week agreed to decide whether managed care patients can sue their plans in state courts for 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 Fifth Circuit Court of Appeals ruled that ERISA does not preempt state law actions when HMOs make decisions that involve both eligibility and treatment.
Thus, the Fifth Circuit said, 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.
