Academic journal article Vanderbilt Law Review

ERISA Preemption of Medical Malpractice Claims in Managed Care: Asserting a New Statutory Interpretation

Academic journal article Vanderbilt Law Review

ERISA Preemption of Medical Malpractice Claims in Managed Care: Asserting a New Statutory Interpretation

Article excerpt


If Congress wants the American citizens to have access to adequate health care, then Congress must accept its responsibility to define the scope of ERISA preemption and to enact legislation that will ensure every patient has access to that care.1

Congress enacted the Employee Retirement Income Security Act of 1974 ("ERISA")2 to protect employee interests3 and ensure a uniform body of law for pension and benefit plans.4 The statute's expansive preemption clause5 and preclusion of extra-contractual damages6 have since been used to immunize Managed Care Organizations ("MCOs")7 from liability for patient8 injuries resulting from medical malpractice. Because plaintiffs with preempted claims may receive only the remedies provided for under ERISA-the right or benefit due under the plan9-many injured patients have been left with no meaningful remedy.10

"[N]ot a model of legislative drafting,"11 the statute's broad preemption clause provides that state law claims that "relate to" an ERISA plan are preempted.12 The ambiguous phrase "relate to" has been the primary focus of the Supreme Court's attempts to determine the reach of the preemption clause.13 Relying primarily on a textual interpretation of the statute, the Court has held that, while ERISA does not preempt "run-of-the-mill state-law claims,"14 those plans that have a "connection with or reference to"15 an ERISA plan, without being a "tenuous, remote, or peripheral connection,"16 are preempted. The Supreme Court's tortured attempts to give effect to the statutory language have led to doctrinal confusion and "chaos" in the lower courts.17 Little judicial guidance, therefore, currently exists for interpreting ERISA's poorly constructed preemption clause.

ERISA is implicated in medical malpractice claims through its regulation of employee welfare plans.18 An "employee welfare benefit plan" under ERISA is a "plan, fund, or program" that an employer establishes or maintains to provide medical, surgical, or hospital care or benefits to participants through the purchase of insurance.19 Employer-provided health insurance, therefore, has been interpreted as an employee benefit within the scope of ERISA. If a state cause of action involving health care provided through an ERISA plan, such as a medical malpractice claim, is deemed to "relate to" the employee benefit plan, the cause of action is preempted by ERISA under section 514(a).20

Although most courts agree that direct liability actions against MCOs21 are limited to remedies provided by ERISA, vicarious liability claims against MCOs22 have divided federal courts,23 leading to calls for legislative action.24 While the Supreme Court has not yet spoken directly to the case of a medical malpractice claim against an MCO, lower courts are increasingly adopting the reasoning put forth by the Third Circuit in Dukes v. U.S. Healthcare, Inc?25 The Dukes court held that ERISA preempts claims interpreted as a denial of benefits, but not those claims challenging the quality of care of benefits received.26 Appealingly simple, this distinction may ultimately prove untenable; often a reasonable argument can be made for an action based on either a denial of benefit or substandard medical care.

The current jurisprudence of ERISA preemption contravenes both of the congressional goals set forth for ERISA. First, the interests of employees are not being protected. ERISA's broad preemption clause has left many injured patients without meaningful remedy. Second, the body of law for benefit plans is not uniform. There are differences in the treatment of direct and vicarious liability claims, employer-provided health care and non-employer-provided health care, self-insured plans and commercial insurance, and hospitals and MCOs.27 Despite calls for legislative action, Congress has been unsuccessful in passing legislation amending ERISA to better protect health care plan members.28

Courts have the power to interpret the statute to comply with ERISA's goals of employee protection and uniformity. …

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