Supreme Court Endorses Broad ERISA Preemption of Pure Eligibility Determinations by Plan Administrator; Federal Court the Exclusive Forum for Such Claims; Overlapping State Law Causes of Action Not Permitted

By Stempel, Jeffrey W. | Journal of Risk and Insurance, December 2004 | Go to article overview

Supreme Court Endorses Broad ERISA Preemption of Pure Eligibility Determinations by Plan Administrator; Federal Court the Exclusive Forum for Such Claims; Overlapping State Law Causes of Action Not Permitted


Stempel, Jeffrey W., Journal of Risk and Insurance


Aetna Health, Inc. v. Davila, 124 S. Ct. 2488, 159 L.Ed. 2d 312, 72 U.S.L.W. 4516, 2004 U.S. LEXIS 4571 (United States Supreme Court--March 23, 2004)

Juan Davila was a participant in an employer-provided benefit plan subject to ERISA (the Employee Retirement Income Security Act of 1974) and Ruby Calad was a beneficiary under another such plan. Under the terms of Davila's plan, administered by Aetna Health, Inc. (formerly Aetna U.S. Healthcare), requests for coverage and payment to health-care providers are reviewed by Aetna. Cigna Healthcare of Texas provided similar administration of Calad's plan.

Davila experienced arthritis pain. His treating physician prescribed Vioxx. Aetna refused to pay for reasons not stated in the Court's opinion but presumably because Vioxx was not a prescription medication included in the plan's coverage for arthritis. Davila did not contest or appeal this decision and did not buy Vioxx on his own. Instead, he purchased Naprosyn, "from which he allegedly suffered a severe reaction that required extensive treatment and hospitalization." See 124 S. Ct. at 2493.

Calad underwent surgery. Her treating physician recommended an extended hospital stay. However, a CIGNA discharge nurse "determined that Calad did not meet the plan's criteria for a continued hospital stay." As a result, CIGNA denied coverage for additional hospital days. Calad "experienced postsurgery complications forcing her to return to the hospital," injury she attributed to CIGNA's failure to extend her hospital stay. See 124 S.Ct. at 2493.

Both Davila and Calad sued Aetna and CIGNA, respectively under the Texas Health Care Liability Act ("THCLA," Texas Civil Practice and Remedies Code Ann. [subsection]88.001-88.003), alleging that the defendants had been negligent and failed to exercise adequate care making coverage decisions under the plans and that these failings caused the injuries they experienced. The suits were filed in Texas state court. Aetna and CIGNA each removed the respective cases to federal court, on the ground that ERISA was the exclusive cause of action for such claims and that as such, the ERISA statute completely preempted the Texas state courts (or any state courts for that matter) from hearing the claims.

"Removal" is a legal device in which a case originally filed in state court is transferred to the local federal court pursuant to statute (28 U.S.C. [subsection]1441-1448) because of the dominance of federal claims and the defendant's right to have the claims heard in a federal court, which is historically presumed to be less hostile to nonresident defendants and more competent in construing federal claims so that the defendant's rights are fully considered under federal law. Where a mixture of federal and state claims or causes of action (theories for requesting relief, such as breach of contract, commission of a tort, trespass upon property) is made in a complaint, the presence of the federal claim is generally enough to justify the removal of the case to federal court.

The Davila and Calad claims were a bit unusual in that neither expressly based claims for relief upon ERISA but rather drafted the complaints to allege only violation of THCLA and other state claims, without mentioning ERISA. The defendants were only too happy to point out in their removal papers that the claims inherently involved employee benefit plans subject to ERISA. From this, the defendants argued that removal from state to federal court was not only proper but was in fact required even if the Davila and Calad complaints did not specifically plead ERISA violations and claims. Further, and perhaps more important for purposes of benefits law, Aetna and CIGNA argued that they were not only entitled to a federal court forum for the dispute but that the same complete preemption that required removal prevented suit against a plan administrator under the Texas state law.

Generally, the existence of federal claims is determined by examining the face of the complaint. …

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Supreme Court Endorses Broad ERISA Preemption of Pure Eligibility Determinations by Plan Administrator; Federal Court the Exclusive Forum for Such Claims; Overlapping State Law Causes of Action Not Permitted
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