Academic journal article American Journal of Law & Medicine

Managed Care: No Standing to Sue under RICO-Maio et Al. V. Aetna Inc. et Al

Academic journal article American Journal of Law & Medicine

Managed Care: No Standing to Sue under RICO-Maio et Al. V. Aetna Inc. et Al

Article excerpt

Managed Care: No Standing to Sue Under RICO-Maio et al P. Aetna Inc. et aL1-The Third Circuit, in affirming the District Court, held that plaintiffs in a class action cannot sustain a claim under the federal Racketeer Influenced and Corrupt Organizations Act ("RICO")2 against Aetna without alleging that the health care they received was actually compromised or diminished as a result of Aetna's decisions.3 The appellants, Joseph and Jo Ann Maio and Gary Bender, filed suit on behalf of themselves and millions of past and present Aetna HMO members. They alleged that Aetna violated RICO by attracting customers with false marketing by promising to provide higher quality care than is available under traditional fee-for-service plans, and then did not deliver the care it promised due to policies and procedures that were designed to increase profitability.

To obtain standing under RICO, a plaintiff must show that there was an injury to either business or property,30 and that the injury was proximately caused by the defendant's violation of RICO. The appellants did not allege any actual injury or denial of benefits resulting from the provision of substandard health care. The appellants argued that the damage element of their claim was the financial loss resulting from paying too much for the health insurance they received from Aetna. The allegations were that the health-care plans the appellants purchased were not worth as much as Aetna advertised. This is demonstrated by the decrease in the value of their property, their health insurance coverage.

The appellants claimed that Aetna advertised high quality health care, while in actuality Aetna was pressuring health care providers to cut costs and minimize the health care services provided. Systemic policies that allegedly inhibit physicians' abilities to provide high quality care include: (1) Aetna's policy that permits overriding a physician's decision of what care is medically necessary; (2) Aetna's power to unilaterally amend all terms of provider contracts; and (3) Aetna's incentives for physicians to withhold services.

The court stated that there was no factual basis for the appellants to claim that they were injured.4 An essential element of a civil action pursuant to RICO is the existence of a cognizable injury to business or property. …

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