Difelice v. Aetna U.S. Healthcare

letter, father in relevant facts. that available the United the level of “[djon’t write letters admonishes Miah States. to consider this fact home.” IJ failed letter, the IJ indicat- the father’s As to opinion clearly in and it is relevant to her regarding in detail lacking it “is ed that determining explained whether Miah has incidents.” Id. at 35. any alleged of the failure to corroborate. his may provide father not de- While Miah’s Miah, on he does about attacks tails III. Conclusion in made Miah’s allegations confirm other Accordingly, the reasons stated the letter is translat- Though claim. above, we Miah’s Petition to Review English, grant the father con- perfect ed into BIA, missing and the Order of the vacate the BIA’s firms that Miah’s brother is order, conjunction the matter to the BIA police, acting and remand refusing coop- pro- to instruct the IJ to conduct further League, the Awami ceedings opinion. him. He further indi- consistent with this finding erate League that Awami workers are cates

circling family’s home in cars and family attempt in an

threatening the Again, of Miah.

learn the whereabouts must determine whether Miah has

IJ sus- proof by producing

tained his burden of corroborating

such evidence in addition to testimony. credible his DIFELICE, Jr., Joseph Appellant V. If the IJ nonetheless determines Miah has not corroborated the relevant HEALTHCARE; AETNA U.S. Michael facts, then the IJ must determine “wheth- Picariello, M.D.; Fowler; Ear Sarah applicant adequately explained er the has Nose & Throat Assoc. of Chester Abdulai, his or her failure to do so.” County, Inc.; County Hospi Chester previously F.3d at 554. The IJ concluded tal. that Miah provided had “not or indicated No. 02-3381. attempted that he to obtain letters or affi- store, employees davits” from at Appeals, United States Court of BNP, other from members other Third Circuit. family. members of A.R. 35. his While offering opinion no this time as to Argued March 2003. expect whether it would be reasonable to Filed Oct. to obtain letters or affidavits Miah from employees and other members of the

BNP, recognized we BIA above that the that, generally, applicant

has indicated reasonably

can expected produce let- family remaining

ters members applicant’s country. home See In re

M-D-, supra. We instruct the IJ to con- the letter from Miah’s

sider father as-

sessing adequately whether Miah has ex-

plained his failure to corroborate certain Devine, Norristown, (Argued),

James I. PA, Appellant. for Schell, Sprague,

Jonathan B. Post & (Ar- Jr., Roy Philadelphia, Englert, T. PA Robbins, Russell, gued), Englert, Orseck Untereiner, DC, Washington, Appel- & for lee Aetna U.S. Healthcare. Pitt, Kilcoyne

Michael O. James P. & Associates, Plymouth Meeting, Ap- PA Picariello, Fowler, pellees Michael Sarah Assoc, Ear Nose & Throat of Chester County, Inc. Aetna, Wilson, Williams, mainte- is administered a health White &

Cathy A. PA, County (“HMO”). Paoli, Appellee Chester organization nance Under Hospital. plan, is entitled to terms of this DiFeliee there certain “Covered Benefits.” Unless BECKER, Judge,* Before Chief provision particular type for a specific is a AMBRO, Judges. Circuit RENDELL and if, treatment, only covered in benefit is Aetna, it “Medical- the determination of THE COURT OF OPINION “Medically Necessary” is a ly Necessary.” RENDELL, Judge. Circuit term, meaning sup- or defined the service deter upon called again We are once likely be “care treatment as ply must or claiming medical mine whether a lawsuit as, produce significant positive outcome by the negligence completely preempted likely negative produce and no more provision Employ civil enforcement than, any outcome alternative service or Security Act ee Retirement Income supply;” diagnosis must be “related to 1132(a). (“ERISA”), Joseph 29 U.S.C. existing injury;” may “include illness Jr., DiFeliee, appeals the order of the V. only supplies services and that can- those East District Court for the United States safely satisfactorily provided at not be and Pennsylvania dismissing ern District of his home;” and, and diagnosis, “as care Healthcare, against complaint Aetna/U.S. (tak- treatment[, costly be no more must] (“Aetna”) negligent conduct in re Inc. for account in- ing expenses into all health sleep gard to his medical treatment for curred connection with the service or Di apnea upper airway and obstruction. supply) any equally than effective service court, alleging filed suit in state Feliee supply.” physi to his treating Aetna’s instruction designed cian that a tracheosto- specially In diagnosed March DiFeliee was my “medically unnecessary” tube was “sleep apnea/upper airway obstruc- discharged insistence that he be Aetna’s tion,” required for which he tracheosto- attending phy hospital from the before his doctor, my tube.1 His Dr. Michael Picar- appropriate sician deemed it amounted to iello, surgically tracheostomy inserted a negligent conduct under law. Aetna state obstruction, tube eliminate but the ease to court on the removed federal continually tube came Dr. out. Picariello then preemption basis of ERISA placed specially then order for a de- moved to dismiss the claim. The District However, signed tube. Aetna instructed Court, Pryzbow relying on our decision in special Dr. Picariello that tube was Healthcare, Inc., ski v. U.S. 245 F.3d 266 “medically unnecessary.” Instead of or- (3d Cir.2001), that the claim was com held tube, dering special the doctor then pletely preempted and dismissed it its tube, inserted a different which caused follow, entirety. For the reasons that we pain DiFeliee severe and resulted in an will affirm in part part. and reverse infection. DiFeliee was later admitted to I. treatment, County Hospital Chester but, avers, the complaint in an was thereafter participates ERISA-gov- DiFeliee employee erned “at discharged welfare benefit Aetna’s insistence.”2 * Judge completed Becker his term as 1. Our recitation Chief facts is derived from complaint. Judge May DiFeliee's on objects

2. DiFeliee to our consideration of the administration, complaint DiFelice filed a five-count ter of and because Aetna Philadelphia Pleas Common actually was not in providing any involved Aetna, his against treating physicians, medical services to DiFelice. ap- DiFelice I, alleged he hospital. Count peals the District Court’s order dismissing negligently Aetna interfered with his medi- Count I. “by instructing

cal care Dr. Picariello that specially designed tracheostomy tube II. necessary he medically deemed unnec- jurisdiction We over the District essary improperly [DiFelice] inter- final pursuant Court’s order to 28 U.S.C. Dr. fering with Pieariello’s medical deci- and review the Court’s exercise of concerning tracheostomy sion tube and jurisdiction and order of dismissal de novo. insisting on the discharge [DiFelice’s] Pryzbowski, at 245 F.3d 268. Aetna ... bears [hospital] attending physi- before his the burden proving jurisdic- the federal discharging cian on planning [him].” was it against Spectacor Mgt. The other counts involved claims tion seeks. Group v. Brown, (3d Cir.1997). parties 120, other than Aetna. Aetna removed 131 F.3d 127 to the case the District Court on the In reviewing complaint, the we ac- must the claim it grounds against that was com- cept as true all of DiFelice’s factual allega- preempted under then pletely ERISA and tions and draw all reasonable inferences opposed moved to dismiss. DiFelice the Langford City therefrom. v. Atlantic motion to dismiss and moved remand to (3d Cir.2000). City, 235 F.3d 847 state court. challenges DiFelice the District Court’s The District Court denied DiFelice’s mo- jurisdiction removal I over Count of his tion granted to remand and Aetna’s motion complaint and asks us to remand to state I, as to granted dismiss Count argues court. He negligence his ac- motion to remand on the remaining counts against entirely tion Aetna is a matter of against parties. the other The held provides state law and no basis for remov- disposition I of Count was al. Aetna counters negli- that DiFelice’s “squarely controlled the Third Circuit’s gence action is in nothing fact more than ” in Pryzbowski, decision which we held an action to recover due under benefits his a claim challenging the “administra- plan, and as such completely preempted is eligibility tion of or for benefits” was com- by the civil provision enforcement 502(a)(1)(B) pletely preempted by section 502(a). ERISA, section Pryzbowski, of ERISA. 245 F.3d against The Court reasoned that the claim A. Framework completely Aetna was because “well-pleaded DiFelice Under com challenging was Aetna’s decision rule, plaint” question jurisdiction that he was not entitled to the federal special tube Plan, under entirely only which was a mat- exists where an issue of law federal Here, determining terms of the Plan in whether his reference "medical DiFelice’s neces- complaint sity” clearly should be he dismissed because derived from the terms of the Furthermore, complaint, does not reference the Plan in his Plan. did even if Aetna not ex- argue plicitly argue provisions and Aetna did not that the below Plan that the Plan con- However, case, provisions dispositive. were in rul- trolled the decision in Aetna at- this dismiss, ing may on a motion to we Plan consider tached the as an exhibit to its brief and "integral” an extrinsic to the document motion before District Court. DiFelice complaint. Burlington Factory certainly See In re Coat on notice that Plan terms (3d Cir.1997). Litig., integral argument. Sec. 114 F.3d were to Aetna’s to him under ... recover benefits due complaint. the face appears on 29 U.S.C. plan.” the terms of his Labor Bd. Cal. Const. Tax Franchise 1132(a)(1)(B). an ac- Cal., 1, § The line between 463 U.S. Trust S. ers Vacation (1983). benefits, challenges tion to recover L.Ed.2d 420 regarding decision rule: administrative However, exception to this there is an a certain benefit is covered claim “comes whether purportedly state-law when alleging an action plan, an ERISA exclusively] federal scope of [an within the malpractice, which chal- negligence un action,” “necessarily ‘arises cause of actually pro- treatment law,” completely lenges the medical and is federal der’ blurry patient, is a one. We Id.; Nat’l vided to also see preempted. Beneficial — —, continually refining precise Anderson, have been Bank v. (2003) evaluating such claims. 2058, 2062, test we use 156 L.Ed.2d S.Ct. effect of preemptive (explaining syn- recently, Pryzbowski, we Most ERISA). before us is there question in our the discussions contained thesized law DiFeliee’s claims of state fore whether opinions adopted preferable previous fall within of Aetna negligence part on terminology. explained We new of action the federal causes scope distinguish past attempted we had 502(a) ERISA, of in section provided quality at the of claims directed between is, the claims could been whether - is, treat- received that as to the benefits so, If then that section. brought under - within section ment which would not fall claim would of the federal the existence 502(a), plans errone- and claims that the question ju for federal provide basis benefits ously quantum withheld a time would re but at the same risdiction - the administration of the focusing due on complete preemp on quire dismissal based completely plan which would be tion. 245 F.3d at 272. preempted. Pryzbowski, rubric, Following “quality-quantity” this occasions to con- have had numerous We an that an plaintiffs allegation a we had held that question of whether sider the reasonable by sec- had failed to exercise an HMO is covered HMO against claim 502(a) treatment was completely providing care medical tion and is therefore Dukes, 358; See, 57 F.3d at an preempted, 245 not e.g., Pryzbowski, preempted. 273-75; policy of dis- Hosp., allegation v. Pa. 237 HMO’s F.3d at Lazorko (3d Cir.2000); 24 hours after 242, charging In re newborns within U.S. F.3d (3d Inc., 151, delivery essentially a medical Healthcare, 162-63 their 193 F.3d Healthcare, Inc., Cir.1999); preempted, not In determination and was Dukes v. U.S. Cir.1995). Healthcare, 163; (3d 350, re 193 F.3d at Determin- U.S. 57 F.3d financial di- allegation have been that an HMO’s ing whether a claim could discouraged providers proven has to be sincentives brought under ERISA fact, mentally ill hospitalizing In as a woman anything but an exact science. care” claim because it concurring opinions point “quality was a my colleagues’ well, in the course of a treatment deci- the exercise seems to have occurred out all too sion, own, preempted. very and not a and was therefore taken on a life of its Lazorko, F.3d at 250. life at that. satisfying productive event, and our case law the statute However, Pryzbowski, found the we must follow. path chart the we unclear, and “quality-quantity” distinction 502(a) terminology suggested helpful civil actions to that more Section allows for in Pe- beneficiary was utilized brought “by participant be a Herdrich, 120 S.Ct. ful and reasonable gram v. decisions as to health- (2000). care.” Id. at 274. Although 147 L.Ed.2d 164 Were those claims on Pegram “concerned fi- based a treatment decision or on recognized we determination pre- eligibility under ERISA and not as to for a duciary acts bene- fit? explained We emption,” analyzing “[i]n we found useful “the distinction decisions, eligibility whether a claim falling made there between between the[ ] two plan’s coverage poles turn is completely preempted, on it is neces- 502(a).” sary to refer particular procedure condition or medical Id. at 273. treatment,” essence, Paring for its and “treatment deci- the issue down to its we sions, in diagnosing which are choices and stated that the relevant question must be condition,” whether the claim treating patient’s and deter- “could have been the subject of a civil “equally mined that the distinction was enforcement action 502(a).” have, If it applicable complete preemption analy- Id. could then it was claim, Pryzbowski, (quoting Congress sis.” 245 F.3d at 273 benefit has 2143) clearly expressed intent Pegram, 530 U.S. at 120 S.Ct. its that the claim (emphasis quotations preempted by (citing added and internal ERISA. Met- omitted). ropolitan explained, Taylor, We then Ins. Co. v. 481 U.S. Life 58, 66, 95 L.Ed.2d 55 used, Regardless language (1987)). pur- ultimate distinction make for

poses complete preemption is whether Because the claims in Pryzbowski fell challenges the claim the administration poles, between the two we took extra care benefits, eligibility of or which falls complaint plead- examine the for “artful scope within com- ing,” Pryzbowski to ensure that was not pletely preempted, quality or the of the disguising eligibility claim that could performed, medical treatment brought have been under ERISA as a may subject be the of a state action. state law negligence explained claim. We that, the claim although might be “ostensi- Id. bly provision directed at the of medical nomenclature, Using this it was evident treatment,” beyond we to “look needed Pryzbowski to us in alleging “a claim face of the complaint to determine whether physician that a in knowingly delayed per [Pryzbowski artfully pleaded had] his suit forming urgent ... surgery would relate so as to couch federal claim in terms of care,” quality to the while on the other Jass, law.” (quoting state Id. at 274 88 hand, “a alleging claim that an HMO de 1488); Bd., F.3d at see also Franchise Tax to approve requested clined certain medi (“[A] plain- S.Ct. ground cal services or treatment on the may tiff [to not defeat removal federal they not were covered under the by omitting plead necessary court] fed- manifestly regarding would be one questions complaint.”). eral in a The ulti- proper administration of benefits.” Id. whether, question mate was the ba- when (citing Jass v. Prudential Health Care understood, the claim properly sis for was Plan, (7th Inc., F.3d 1488-89 Cir. the claim fell under ERISA. 1996)). However, presented we were carefully there with claims that fell in examining Pryzbowski’s somewhere After claims, negligently complaint between: that an HMO had true of his bases delayed of an approval spe completely out-of-network we held that his claims were cialist, First, supervise preempted. regarding delayed and that it had failed to properly employees “thought- approval, underlying its to make we concluded that of action could have formed the was a the cause negligent activities allegedly HMO’s to and of a suit under that section. regarding payment basis policy decision specialists, of out-of-network approval below, when we fully As discussed more of the “within the realm decision that fell to the Pryzbowski framework apply Pryzbowski, of benefits.” administration us, that Di- complaint before we conclude that this explained at 273. We 245 F.8d “interfered with” Felice’s claim that Aetna under brought have been claim could by declaring treatment his medical sought Pryzbowski “[h]ad ERISA because “medically unnecessary” tube special approval [the HMO]’s to accelerate it could preempted by ERISA because she could providers, use of out-of-network under sec- brought have been as an action 502(a) injunction sought 502(a). However, appears tion because was to which she to enforce the benefits that he was dis- that DiFelice’s claim at 273-74. plan.” entitled under the “at the insistence of Aetna” does charged Further, had claim that the HMO her any discharge policy set forth not rest on hire, train, super- properly “failed to benefit, Plan, any agreed in it would thoughtful make employees vise its avail- encompassed not be within the relief reasonable decisions as to healthcare” able under section and is therefore because, reading also behind completely preempted. pleading, negligence” the artful “medical that the complaint allege did not HMO Tracheostomy B. The Tube actually in engaged had employees or its will first examine DiFelice’s We Id. at 274. Be- any medical treatment. Dr. Picar claim that Aetna interfered with in only role was adminis- cause the HMO’s regarding spe iello’s medical decision benefits, it could not Pryzbowski’s tering Pryzbowski, cial tube. Under the first providing possibly negligent have been question is whether Aetna’s “medical ne the situation treatment. Id. Unlike cessity” clearly either a determination is an admin- which an fills dual roles as HMO eligibility medical treatment decision or an provider of ser- istrator of benefits and decision. DiFeliee has couched this claim vices, actually might engage therefore negligent of Aetna’s interference terms treatment, there was HMO care, imply with his which seems acting solely as an administrator. engaged Aetna in medical treatment. itself However, complaint to does not in Pryzbowski thus instructs us deter- DiFelice’s any allegation clude that Dr. Picariello was mine whether a claim is 502(a) Aetna, examining agent whether an not by section first Aetna did monitoring two exercise care in Dr. poles, the claim falls at either of the reasonable care, entirely entirely pro administra- Picariello’s or that Aetna itself treatment or treatment; rather, solely tive. If on a medical treat- vided medical his claim based decision, ment the claim is not rests on Aetna’s “instruction” to Dr. Picar then specially designed If an adminis- iello “that the tracheos preempted. based on HMO decision, tomy necessary eligibility trator’s then the claim tube he deemed was medi unnecessary,” preempted. cally In the more difficult situa- a direct reference in necessity” tion in which the claim falls somewhere “medical determination between, complaint Looking we called for in the Plan. behind must scrutinize pleading,” language sounding for “artful and then refer to DiFelice’s use of 502(a) negligence, alleging whether he is that Aetna section itself and determine alleged underlying wrongfully coverage the actual denied him for the wrongdoing 502(a) Thus, the has as- under section special complaint challenging tube. HMO’s is, coverage. That pects of treatment determination that sex change operation determination, Aetna neces- making its “medically was not necessary”); Fritcher judg- sarily had to exercise some medical Corp., v. Health Care Serv. 301 F.3d ment, i.e., (7th it had to determine whether the Cir.2002) 814-15 (reviewing claim un likely produce “as a special tube was 502(a) der section challenging HMO’s de as, positive outcome and no significant termination that custodial care was not likely negative outcome produce more “medically necessary”); Kopicki v. Fitz than, ... supply, alternative service or gerald Auto. Family Employee Benefits diagnosis existing related to of an [was] (D.Md.2000) Plan, 121 F.Supp.2d ... no injury, [and was] illness more (granting preliminary injunction to prevent costly (taking account all health ex- into denying preauthorization HMO from penses incurred connection with the ser- cancer treatment it had deemed not “medi any equally vice or than effective supply) cally necessary”); see Heasley also v. Bel However, supply.” service or here there (3d den & Corp., Blake F.3d allegation actually provid- is no that Aetna Cir.1993) (reviewing claim under section care, ed the medical and Aetna’s use of 502(a) challenging an HMO’s determina judgment only could led liver/pancreas tion that a treatment anwas treatment, eligibility, decision. “experimental procedure”). DiFelice’s

Because the decision here was in some squarely claim jurispru falls within this sense both a medical treatment and an dence. Because DiFelice’s claim that Aet- decision, eligibility falling between thus na improperly special deemed his tube to poles Pryzbowski, two discussed we “medically unnecessary” could have must refer to section and determine 502(a), brought been under section it is claim regarding whether DiFelice’s completely preempted by ERISA. We subject tube could have been the of a civil will affirm therefore the District Court’s Pryz action under enforcement ERISA. jurisdiction exercise of removal and its or bowski, Clearly, 245 F.3d at 273. it could dismissing der Count I as to Aetna’s con have been. DiFeliee could have chal regarding tracheostomy duct tube. necessity” lenged Aetna’s “medical deter urges DiFeliee that this result is incon- filing mination claim under with the Supreme sistent Court’s decision 502(a)(1)(B) “to recover due benefits in Pegram and our decisions in U.S. plan,” him under the terms of his disagree. Healthcare and Lazorko. We arguing special tube was in fact Pegram, Court an “medically necessary,” and was therefore question may swered whether HMO He request “covered benefit.” could have fiduciary duty for a breach of be liable injunction forcing pay ed an Aetna to physician when its owners make “mixed tube, special alternatively, paid the for eligibility and treatment Pe decisions.” the tube himself and then later filed an 229, gram, 530 U.S. at 120 S.Ct. 2143. action for reimbursement. Numerous There, physician, a who was also an owner brought have in fact participants ERISA patient, of the HMO that covered her wait challenging such actions their HMO’s an for the patient’s ed to order ultrasound necessity” “medical determinations rup appendix, appendix inflamed seeking they alleged to recover benefits 215, See, at 2143. The plans. e.g., were due under their tured. Id. S.Ct. Mkts., Inc., patient sued the HMO for breach of fidu Mario v. P & C Food 313 F.3d (2d Cir.2002) 758, (reviewing ciary duty, alleging 762-63 claim that the HMO created and indi against suits HMOs malpractice make physicians for the an incentive interests, guise physicians financial vidual under in their own decisions claims, fiduciary duty interests of in the exclusive breach of rather than ERISA The Court held Id. the distinction between plan participants. and would erode as act as “fiduciaries” that do not HMOs and federal ERISA ac malpractice state physician when their by ERISA 235-36, 120 envisioned Id. at S.Ct. tions. that touch both on make decisions owners above, Pegram, Although, as we noted and the treatment patient’s helpful terminology preemp- for set forth under the for benefits eligibility patient’s Pryzbowski, 245 F.3d at analysis, tion see 218, 120 S.Ct. 2143. Id. at plan. “mixed” holding that a the Court’s a framework first set forth The Court by physician a owner made determination that kinds of acts understanding subject liability an HMO does not an be- acting on HMO’s owners physician fiduciary duty does not translate breach of the one hand On might half undertake. to, in, preemption context. govern ” turning on ‘eligibility decisions’ “pure Rather, Pegram sets a standard for when medi- particular for a plan’s coverage imposed to be on individuals liability is treatment, are “treat- and on the other cal fiduciary capacity. in a It does acting decisions,” go about how to

ment choices encompass ERISA claims en- presume to treating patient’s a diagnosing and about fact, Pegram as such. In forcement In 120 S.Ct. 2143. condition. Id. at it that was not specifically Court stated “eligi- situations which between are a claim discussing governing the standards decision and the treatment bility decision wrongfully had denied patient that been mixed,” is, that when an inextricably [are] nor the interac benefits due under a plan necessarily rests on the eligibility decision and state law tion between such a claim judgments about reasonable “physicians’ at 229 Pegram, of action. 530 U.S. causes Id. The Court found medical treatment.” 2143; Roark v. Hu n. 120 S.Ct. accord just such presented it was (5th Inc., mana, 298, 308 Cir. 307 F.3d had physician owner “mixed” decision: the 2002) has (stating that the Court “condition patient’s determined 502(a)(1)(B) action; the con- not decided whether section did not warrant immediate claim in sequence malpractice of that medical determination a medical preempts im- decisions,” not cover holding would un volving [the HMO] “mixed but not). mediate care.” Id. it der Fifth Circuit law that does fact, allowing plain argued it could be be- Having concluded that the decision by around ERISA tiffs to do end-run decision, fore was “mixed” them to decisions permitting couch physician HMO’s went on to hold impact on treatment that have some owners do not act as fiduciaries terms have a similar ef negligence would making such decisions. ERISA when undermining as was feared fect of 2143. The Court focused con Pegram. We remain the Court “fiduciaries,” explaining on the nature that, look at Pryzbowski, after we vinced not “fiducia- that these mixed decisions are enforcement, subject what decisions are nature,” “only limited ry in and bear radically inquiry which is a different trus- resemblance to the usual business of an sued for breach of when can HMO be The that a con- tees.” Id. Court feared duty.3 fiduciary trary open floodgates would result determining paths appeals in We that other federal courts of have followed different 3. note

451 persuaded “policy that U.S. HMO’s and incentive structure are also We of which Healthcare and Lazorko both [patients] were such that the never had the rely on the pre-date Pryzbowski and option making an informed decision as - compel a “quality-quantity” distinction to whether to for the pay hospitalization Healthcare, we different result. U.S. themselves, as occur in a would situation in challeng- against that a suit an HMO held coverage sought and denied.” Id. ing policy pre-certifying twenty- its Although analyzed we claims U.S. discharge four hour of mother and new- Healthcare under the “quality-quantity” preempted born was not ERISA be- rubric, holding our squares pre- with the quality cause it went to the of the health emption framework we later set forth in Healthcare, 193 F.3d provided. care U.S. Pryzbowski plaintiffs Because the in U.S. noted that Significantly, we suing Healthcare were not benefits plaintiffs allege pro- did not “a failure to plan, due under the but rather were chal- plan,” vide authorize benefits under the itself, lenging plan they could not have they they nor did claim “that were denied 502(a), therefore, sued under section any of the benefits that were due under Pryzbowski even under their claims would Rather, they alleged that plan.” not have preempted. been negligent adopting was the HMO Lazorko involved a similar issue. supervising discharge policy and There, we held a claim that financial they physicians with whom contracted imposed by disincentives an HMO discour- services, and that the HMO’s incentive aged providers hospitalizing medical adversely physi- structure affected the a patient who later committed suicide was judgment regarding when cians’ medical a “quality of care” claim and therefore not discharged. newborns should be Lazorko, preempted. 237 F.3d at 249-250. plaintiffs seeking were not to enforce ben- We noted that Lazorko was not claiming they thought due to them under efits were supposed the HMO was to in- plan; they challenging were the dis- hospitalization, clude but rather that her charge itself and the HMO’s actions policy doctor was influenced his decision-mak- provider arranger “in its role as a services,” ing by the incentive structure. Id. As in medical not in its role as admin- Healthcare, patient istrator of benefits. Id. at 163. The could not proper whether a claim is under section nose a and authorize medi condition concluded, 502(a). Some have on the facts cal treatment were tort claims outside of them, Does, 502(a)); challenging scope before that a suit "medi of section Cicio v. 321 83, (2d Cir.2003) (concluding necessity” preempted, cal determination was F.3d 102 Watters, Pegram, malprac see Marks v. 322 F.3d 326-27 a state law medical Cir.2003) (4th (holding against suit tice action based on a “mixed” decision is not manager preempted by HMO utilization review case was ERISA when the state law completely preempted "challenges allegedly under section cause of action actually provide judgment applied par because the HMO did not flawed medical as to a treatment); patient’s symptoms”); medical Jass v. Prudential Health ticular Roark v. Huma Plan, Inc., (7th na, Inc., (5th Cir.2002) Care 88 F.3d Cir. F.3d 1996) (holding negligence against (holding that a claim an HMO failed that a claim that had ordinary making manager an HMO utilization review case care in to use completely preempted necessity because the claim was in tort and determination sounded benefits”), preempted). "in effect a claim for denial of was not We believe that Pryzbowski pro some have concluded that it was not. See framework we set forth in Fla., controlling analysis Land v. CIGNA Healthcare here F.3d vides the method (11th Cir.2003) (holding compels the conclusion that DeFelice’s correctly diag- regarding preempted. claims that an HMO failed to claim the tube is to the respect of the claim with missal because she nev- under ERISA have sued tube. continued option seeking the er had doctor, as influenced her

hospitalization Hospital Discharge from the C. The not offer it to her. did by policy, HMO the a claim that Aetna I includes Count also Id. med- interfered with DiFelice’s improperly Lazorko, and in U.S. Healthcare Unlike by “insisting [his] on dis- ical treatment denial a here, on suing DiFelice is based his [hospital] ... before charge from the under the was due he claims he benefit planning on dis- attending physician was negli- that Aetna claiming not Plan. He is District did charging [him].” policy regard- a adopted particular gently of the claim its aspect not address this imposed an in- tracheostomy tubes or ing dismissing complaint. order with his that interfered centive structure regarding the tra Unlike his claim judgment. independent medical physician’s tube, allege not cheostomy DiFelice does Rather, special tube was he claims that the stay to be hospital Aetna deemed the that that unnecessary,” and Aet- “medically not not “medically unnecessary” and therefore was, it a determined that wrongfully na by Plan. The claim also does covered language that is based on claim policy in rely discharge on a appear not nature of benefits pertains Plan and to the Indeed, it any agreed Plan benefit. in U.S. plaintiffs provided. Unlike vague to tell from DiFelice’s is difficult Lazorko, sought and DiFelice Healthcare precisely alleging he is pleadings what benefit, coverage for a and was denied the form this “insistence” Aetna did or for the benefit himself paid could way If forced the took. Aetna some 502(a) reimburse- under sued section him, fi discharge imposed hospital ment. in U.S. nancial incentives like those unduly af Healthcare and Lazorko that under our most recent control- Because Di- physician’s judgment, his then fected Pryzbowski, DiFelice’s ling precedent, negligence has cause of ac pled Felice in deter- negligent claim that Aetna was by preempted tion that ERISA. special tube was “medi- mining unnecessary” cally stage, could have been it was Aetna’s At the dismissal jurisdiction by subject prove of a suit under section burden to federal Plan, claim is claim. See proving due under the his that this is ERISA benefits at Group, We will there- 131 F.3d preempted Spectacor Mgt. ERISA.4 nothing apparent plead- from the affirm the District Court’s exercise of There fore that would foreclose DiFelice from jurisdiction subsequent ings dis- removal dispute” the statute "related to” argues deci- serious 4. Aetna that the Court’s HMO, Moran, preempted therefore and was Rush Prudential Inc. sion in 2151, 1144(a), 29 U.S.C. but went on 122 S.Ct. 153 L.Ed.2d under result, (2002), preemp- saved compels but we find hold that the statute was this 1144(b)(2)(A) U.S.C. because inapposite. The Court in tion under 29 that case to 365-66, regulated insurance. Id. at faced an Illinois statute that Moran was with Thus, right Court was not faced provided participants S.Ct. 2151. HMO "with challeng- question of whether suit independent review of denials certain benefits,” ing necessity determina- an HMO's medical id. at 122 S.Ct. ERISA ab- provide any tions would be required service that HMOs particular imposed reviewing physician state statute independent deemed sent HMO, which is the "medically necessary.” additional burdens on beyond us here. issue before 2151. The Court held "it discharge that III. being prove able plan was not a benefit. Unlike his decision Because DiFeliee’s claim that in- Aetna erroneously that tube was deter- claim terfered his medical by treatment “medically unnecessary” un- mined to be finding special tracheostomy tube to be Plan, claim on its face is not der the this “medically unnecessary” could have been Therefore, plan-related. because DiFel- 502(a) brought under section of ERISA for discharge iee’s claim of “insistence” on the recovery of benefits due under his give negligence to state law could rise plan, completely preempted. it is We will liability, completely we hold that it is not therefore affirm the order of the District 502(a) by section of ERISA. preempted However, dismissing Court that claim. Aetna because has not shown that DiFel- that, argues Aetna even if DiFeliee’s iee’s claim Aetna that interfered with his discharge cognizable claim is as a hospital by insisting treatment on his dis- action, uphold of state law cause we should charge hospital from the is any based on claim the District Court’s dismissal of that benefit, plan that claim is completely ground on the alternative that it is none preempted. We will therefore reverse the by expressly preempted theless virtue of District dismissing Court’s order ERISA, 1144(a), section 514 of 29 U.S.C. claim and remand proceedings. for further super which provides ERISA “shall any they sede and all State laws insofar as BECKER, Judge, concurring. Circuit any may now or hereafter relate to em I Judge am satisfied that opin- Rendell’s ployee plan” by benefit covered the stat ion reaches the correct result under our However, scope ute. “[u]nlike join governing caselaw. While I thus 502(a)(1)(B), jurisdictional and is her in the I opinion judgment, write creates a basis for removal federal separately my rising add voice to the court, § merely governs the law judicial urging Congress chorus claims, regard that will law apply state Supreme Court revisit what is an un- brought less of whether the case state just increasingly tangled ERISA re- Lazorko, or federal court.” F.3d at gime. 248. As we have determined that the hos Congress enacted ERISA in 1974 “to pital discharge preempted by claim not promote the interest employees 502(a), jurisdiction section we do not have employee their beneficiaries in benefit Rather, question over that claim. Lines, Inc., plans.” Shaw v. Delta Air hospital claim will discharge

whether 85, 90, 2890, 77 L.Ed.2d by law pursuant be controlled federal (1983) Congressional (surveying state- section 514 District by must decided However, purpose). ments of with the rise remand, on should it to exer choose managed care and the Court’s supplemental jurisdiction under 28 cise holding series of decisions 1367(a), by U.S.C. the state court. HMOs, damages against action for ERISA (where Pryzbowski See 245 F.3d at 276 has evolved into shield insulates jurisdiction District Court has over one liability HMOs from for even most claim virtue of preemption under sec egregious acts dereliction committed 502(a), tion it has to decide beneficiaries, discretion against plan state of affairs jurisdic supplemental whether to exercise directly contrary I view as to the Indeed, arising tion over claims from the same Congress. existing intent of court). monetary predicate jurisprudence factual or remand to state creates a or to nominal pension assets to mistreat those ben- HMOs incentive for lower; benefits, whichever was of pension eficiaries, often in the throes who are course, entirely possible plan for a to as- entirely unable crises and assets, happened as they to have zero rights possess. meager what sert shop. frequency when firms closed some to maintain struggled have Lower courts de- provisions contained a raft of ERISA notwithstanding equity some semblance plan participants against signed protect to preemption breadth of the the enormous plan managers. negligent or malfeasant claim is test, turns on whether the one that the Pension Bene- example, For it created alia, by plan, inter to” a benefit “related (“PBGC”), an Corporation fit Guarantee preemp- § 514 exceptions to identifying Deposit Insur- akin to the Federal insurer tion, malpractice for medical such as that protect against to em- Corporation, ance the remedial liability. And in terms of insolvency. ployer 502, they struggled to scope of between out of the distinction make sense plans” protec- “benefit in need of The (which preempted) are - eligibility decisions tion, however, types distinct were of two (which not), are and medical decisions substantially pension and welfare and endeavor, I explain. as shall Un- hopeless animated Con- policy different concerns of all this has been fortunately, price reform in each area. Pension gress’s wherein bog1 into a Serbonian descent employees to which contribute over plans, logical judges are forced to don blinders rely upon the course of their careers and even split linguistic and atom to decide income, provide to retirement were the most routine cases. thought present greater opportunity to far mismanagement underfunding. and

I. plans, plans pension Unlike welfare benefit in- accrue substantial funds that must be A. they prudence, vested with must be was enacted address continuously changing cir- able survive insecurity of increasingly-apparent cumstances. Title of ERISA therefore funds, pension problem workers’ vested managers com- imposed pension plan on recognition through gained national disclosure, prehensive reporting, vesting, as the Studebaker such notorious events funding, fiduciary duty minimum re- plant ap- shutdown which caused quirements. 4,400 to lose their proximately workers plans, Welfare benefit which include pensions. generally See Michael S. Gor- medical, sickness, accident, don, Why surgical, ERISA Enact- dis- Overview: Was Comm, ed?, Senate, death, Special Aging, ability, unemployment, on similar very Employee programs, posed The Retirement Income Securi- different set challenges. pension plans, Decade welfare ty Act of 1974: The First 6-25 Unlike (Information (1984). plans operate “pay you go” Prior to benefit on a as Paper) ERISA, basis, only generally long- to the do not entail workers were entitled bog length. is a from which there 150 miles in Hume said that whole 1. A Serbonian mess extricating therein, way of E. Cobham is no Brewer, oneself. armies have been lost as did Milton: Dictionary Phrase and Fable gulf profound bog, "A as that Serbonian / (First ed.). Hypertext The Serboni 1121-22 old, Betwixt Damiata and Mount Cassius / Egypt bog was between and Pales itself Milton, Where armies whole have sunk.” lake, tine. Strabo called it a and said it was Lost, Paradise ii. 592. broad; long, Pliny 200 stadia and 50 made it crucial plan sponsors H. concession to financial commitments. See John term Wolk, 514(a), A. Pension and form of an express preemption and Bruce Langbein (3d ed.2000). at 176 I Employee provision mandating Law that Titles and IV Benefit ERISA, impose regulations framers therefore saw no need ERISA’s dis- above, on such cussed impose vesting requirements supersede any “shall and all funding Similarly, minimum re- laws insofar as plans. they may State now or guard against hereafter relate to quirements any employee intended benefit on its plan sponsor plan.” Although subject default this section is long-term plan important exception commitments to beneficia- that allows states ries, insurance, impose a minor concern where no substantial to laws regulating see 514(b)(2)(A), exempted funds accrue. The framers thus its is striking. breadth plans fund- explains welfare benefit from ERISA’s The that Con- ing requirements gress as well. intended that plans plan sponsors to ensure and plans is that welfare benefit result subject body would be to a uniform of regulated pension plans. far than less law; goal benefits was to minimize subject reporting, to They are ERISA’s - and administrative financial burden disclosure, fiduciary, and remedial rules - complying of with conflicting directives exempt that govern procedure those but among States or between and States funding vesting from the substantive and ..., pre- Federal Government [and to requirements, guaran- which are meant to potential vent] the for conflict in sub- expected tee a certain level of benefits. stantive law ... requiring tailoring Congress’s relative lack of concern -with of plans employer and conduct regulation plans substantive of welfare peculiarities jurisdic- of the law of each clear from the statement Supreme Court’s tion. not mandate that em- “ERISA does benefits, ployers provide any particular McClendon, Ingersoll-Rand Co. v. 498 proscribe and does not itself discrimination 133, 142, S.Ct. 112 L.Ed.2d in provision employee of benefits.” (1990). premised This view is on the Shaw, In- 463 U.S. at 103 S.Ct. 2890. Dent, Rep. sponsor statement of John of deed, courts have held that the absence of Representatives, the Act the House of vesting provision employers allows purpose who declared that its was to will, plans virtually amend their even the threat conflicting “efiminat[e] See, discriminatory e.g., fashion. regulation.” inconsistent State and local Confer (3d Co., Engine Custom 952 F.2d (1974). Cong. Reg. 29197 Cir.1991) (noting plan sponsor may B.

change prospectively benefits formal notice); v. H & H written McGann Music sense, meaningful Congress’s In a deci- (5th Cir.1991) Co., (upholding 946 F.2d 401 pension employee sion federalize employer’s plan amendment of its appear plan benefit law to have assisted treatment). coverage exclude for AIDS plan sponsors. beneficiaries as much as relatively fight regula- employer Despite required pension ERISA’s No offer plans, plan employees, tion of welfare benefit it is clear that or welfare benefit to its legislation substantially Congress to have established provided were greater safeguards pension regulations merely for both as a federal ERISA’s previ- supplement welfare than had baseline and allowed states to plan beneficiaries fit, i.e., ously they existed. But also contained it as saw had ERISA required health and disabili- law, York statutes employers some state the same as plans ty plans pregnancy to treat to offer such have declined might at a time compliance nonoccupational costs other disabilities rather than deal discrimination jurisdictions. employment federal to individual when tailoring them minimum, compli- passage, not. In a landmark likely statutes did it is At a in a have been reflected the Court stated: would ance costs plan partici- level of benefits lower concluding difficulty have no We undermine course would which of pants, employ- to” laws] York “relate [New From an ex ante ERISA. purpose The breadth of plans. ee benefit therefore, might have been perspective, 514(a)’s pre-emptive apparent reach is as fur- to view even reasonable A language. that section’s law beneficiaries. thering the interests plan, employee “relates to” an benefit phrase, it has the normal sense however, if nothing has been practice, to such a a connection with or generally, reference the truth ERISA further from plan. 514(a) become vir- particularly, § that insulate tually impenetrable 96-97, shields (emphasis Id. at 103 S.Ct. 2890 any meaningful added). liabili- plan sponsors from left the door Although the Court malfeasant acts commit- ty negligent for or ac- ajar by cautioning “[s]ome state in all too plan beneficiaries against ted plans in may employee tions affect benefit in a line of This has unfolded many tenuous, remote, cases. a man- peripheral too that have created a cases Court finding to warrant a that the law ‘re- ner virtually all in which “regulatory 100, 21, vacuum” plan,” to’ the id. at n. 103 lates very preempted are but 2890, state law remedies with or refer- S.Ct. the “connection In provided. are few federal substitutes language ence to” became the test for cases, with Alessi v. began these which future cases. Inc., 504, 451 U.S.

Raybestos-Manhattan, in unani- applied passage The Court (1981), 1895, 402 68 L.Ed.2d 101 S.Ct. holdings Metropolitan Ins. mous Life textualist inter- initially employed Massachusetts, 724, v. 471 U.S. 105 Co. § pretations give (1985) 2380, (holding S.Ct. 85 L.Ed.2d 728 scope. Al- staggeringly preemptive broad mandating mental a state statute relatively straightforward essi was a itself coverage in health insurance group health held a unanimous Court case which 514(a)’s policies preemptive fell within Jersey a New law elimi- by scope, but was saved ERISA’s insur- calculating pension for nated one method exception), ance and Pilot Ins. Co. v. Life that, benefits, whatever reasoning Dedeaux, 41, 1549, 481 U.S. 107 S.Ct. pension clearly law’s it related to purpose, (1987) (holding preempted a L.Ed.2d 39 524, Al- plans. 101 S.Ct. 1895. against state cause action insurer enough, was innocuous though Alessi itself claim). By denial of a the mid- bad-faith determining precedent it established a 1990s, however, it had become clear that by searching scope preemptive ERISA’s the “relates to” standard was one without mean- phrase “relates to” for concrete limits, conceptual given the Court’s ing, eventually approach that would general “assumption po- that the historic chimerical. powers lice of the States were not to be Lines, 85, Act tb superseded 463 U.S. the Federal unless Shaw v. Delta Air (1983), 2890, purpose of 77 L.Ed.2d 490 was the clear and manifest decision, v. Fe Elevator Congress,” another two New Rice Santa unanimous 218, 230, 67 S.Ct. 91 substitute federal cause of action. Corp., 331 U.S. This (1947), specter it at the L.Ed. 1447 balked vacuum” “regulatory creates situations in that could preemptive of a vortex swallow plan which beneficiaries have little or no It virtually any state remedial law. egregious recourse for even the most viola- reversed course New York abruptly rights, tions of their for the remedies con- Blue Cross & Blue State Conference of incapable tained of making Co., Ins. Shield Plans Travelers whole; indeed, in many they victims cases 131 L.Ed.2d 695 S.Ct. actually create incentives for HMOs that, (1995), unanimously where it noted their plan participants. mistreat ‘relate to’ were taken extend to the “[i]f Section 502 contains two subsections indeterminacy, then furthest stretch of its participant’s right address a to recov- practical purposes pre-emption for all wrongs against er for committed course, par- really, would never run its uni (as ticipant personally opposed to those Id. at versally, stop relations nowhere.” (internal itself, against committed 115 S.Ct. 1671 citation omit ted). recognized “simply go It must are considered of the sponsor’s violations unhelpful first, text ... and look beyond fiduciary duty). 502(a)(1)(B), objectives to the of the ERISA instead authorizes the participant beneficiary to guide scope as a to the of the state statute bring a civil action “to recover benefits due Congress law that understood would sur to him under plan, the terms of his 656, 115 vive.” Id. at S.Ct. 1671. rights enforce his under the terms of the plan, clarify or to his rights to future

C. plan.” benefits under the terms of the It above, Congress’s As discussed intent through provision this that DiFelice 514(a) § to preemption behind was ensure might sought injunction an to compel plan sponsors subject would be specialized Aetna to cover the tracheosto- Ingersoll-Rand, uniform law. See second, 502(a)(3), my § tube. The author- 142, 111 U.S. at S.Ct. 478. One critical participant, beneficiary, fiduciary izes a or 502, § - aspect uniformity of this concerns equitable injunctive to seek remedies provision. ERISA’s civil enforcement In against “any practice relief act or which Life, Pilot concluded that Con terms, violates” or ERISA §in gress intended the remedies 502 to be (i) appropriate equitable “other relief of exclusive remedies for violations (ii) such violations or to enforce redress rights guaranteed under It ex ERISA. any provisions” plan. or the ERISA plained pre-emptive that “the force of Although provisions compre- these seem 502(a) § was modeled on the exclusive - glance they hensive at first allow recov- § remedy provided by 301 of the Labor ery of empower par- “benefits due” and Management Congress Relations Act.... ticipant rights” to “enforce his and seek powerful pre well aware - “appropriate equitable they relief’ fact § emptive force of 401 of the LMRA dis operate participants to leave almost com- claims, placed” all state law “even when pletely mercy of at the HMOs. The first action purported the state to authorize a section, 502(a)(1)(B), by plain language its remedy pro unavailable under the federal only plan participants allows to seek the vision.” 481 U.S. at S.Ct. they contractually words, benefits which are § In other preempts state entitled, even when those benefits have ERISA-guaran- causes of action to enforce rights despite teed when no faith and provides even been denied bad finally pro- [ ] of the statute as enacted in need of most participants fact Congress ones least able to did strong are often the vide evidence this section plan participant it. A advantage of other remedies take not intend to authorize HMO’s utiliza- by is denied whose claim ex- simply forgot incorporate that it - DiFelice, Mr. for ex- review board tion assumption of inadvertent pressly. The often in the throes of ample, see suspect especially is rendered admission infra crisis, hardly a feas- a life-or-death medical in- of ERISA’s upon close consideration prosecute and to retain counsel ible time interrelated, interdepen- terlocking, of such injunctive lawsuit. The costs scheme, is in turn dent which remedial immense, ERISA likely to are suits reticulated comprehensive of a part all, fees, only if at attorney provides statute. concludes. See after action (internal citation Id. at 105 S.Ct. ulti- if a 502(g)(1). participant Even omitted). insurer, it will mately his prevails against participant’s estate frequently be the holding narrow left Although Russell’s meager reward. reaps the that extracontractual open possibility many contingency In of law fee damages areas recoverable 502(a)(3)’s a liti are used overcome “appropriate equitable structures relief’ any pos But gant’s impecuniosity. initial subsequent the Court’s decision provision, contingency fees in this sibility using Associates, in Mertens v. Hewitt 508 U.S. preemp context is undermined 2063, 124 L.Ed.2d 161 tion, string Court cases for a (1993), In any hopes. such foreclosed interpreted has ERISA to disallow Mertens, participants sued the fiduciaries dam recovery compensatory punitive plan, alleging of a failed breach fiducia- Wolk, ages. Langbein & Pension and See relief, ry duty seeking monetary Law at 770-75. Employee Benefit they equitable. characterized as Petition- Mutual Ins. Co. v. Massachusetts that, Life beneficiary’s argued “[a]lthough ers 134, 3085, Russell, 105 S.Ct. 473 U.S. resulting action to recover losses (1985), plaintiff under L.Ed.2d 96 sued duty an superficially breach of resembles 502(a)(2),alleging improper pro § that the damages, action at for ... such relief law cessing her benefit claim exacerbated traditionally in has been obtained compen her to her condition and entitled is, equity and courts of therefore defini- punitive damages under satory and tion, 255-56, 113 equitable relief.” Id. at alia, which, 409(a), § inter authorizes S.Ct. ... or remedial relief as equitable “such acknowledged The that may The appropriate.” the court deem in the law of ERISA’s roots lie common Court, however, that recov concluded trusts, see Firestone Tire & Rubber Co. ery 409 must inure to the Bruch, 101, 110-11, 489 U.S. S.Ct. beneficiary. than The Court rather (1989), courts of equi- 103 L.Ed.2d 80 that in explained then dictum that law, 502(a)(1)(B), ty jurisdiction had over trust section allow analogous in recovery, says monetary damages were available those ing participant’s concluded, “nothing recovery of extra-con It against about the courts trustee. damages.” however, tractual Id. at 105 S.Ct. all relief available “[s]ince explained. it passage, 3085. In oft-cited could be obtained from for breach of trust equity, limiting a court of the sort of relief carefully integrated The six civil en- 502(a)(3) ‘equitable §in available under provisions forcement found relief the sense of “whatever relief a faith or otherwise “stiff’ participants. equity provide common-law court of could preempts the state tort of bad- denial, limit such case’ would the relief not at faith claim see Life, Pilot 481 U.S. Mertens, 54-56, 107 all.” 508 U.S. at S.Ct. so that if an HMO way, 2063. Put another interpreting “eq wrongly participant’s denies a claim even “any faith, uitable relief’ to mean relief’ would bad greatest cost it could face superfluous render the word “equitable.” is being compelled to procedure, cover the interpret “eq The Court’s solution was to very cost it would have faced had it uitable” as referring types of relief tra in good acted faith. Any rational HMO ditionally in pre-merger available courts of will recognize faith, that if it good acts in it is, injunctions, mandamus, equity, pay will for far procedures more if than it restitution, monetary damages. otherwise, but not acts punitive damages, might guard otherwise against such unavailability of extracontractual profiteering, are no obstacle at all. Not damages perverse. has effects that are only is there an incentive for an HMO to First, above, contingency as stated fees claim, deny any particular but to the ex - entirely impractical rendered pre- tent practice this becomes wide lawyers cious few would willing to un- spread, it creates a “race to the bottom” in horrendously dertake a complex case of which, all being equal, else profit the most uncertain outcome greatest po- when the able HMOs will be those deny claims merely tential reward is provision of the frequently. most care that had been contractually prom- fees, ised. contingency partici- Without sum, ERISA’s remedial gives scheme pants in the midst of medical crises are every HMOs incentive to act in their own completely mercy at the of HMOs unless their beneficiaries best interest they are enough fortunate to have the simultaneously making while incredibly it financial bring means to a suit for an difficult plan participants pursue injunction, a circumstance which is no what meager remedies they possess, a con- exceptional. doubt Although might founding result for a original statute whose simple injunc- seem a matter to seek purpose protect was to employees. tion compelling contractually-guaranteed coverage procedure, of a nothing is fur- II -

ther from the truth where Mr. as with A. DiFelice availability contractual coverage hinges highly on a fact-intensive Given that ERISA’s remedial scheme determination of medical necessity involv- remedies, provides often no litigants have ing accepted standards of care and tolera- gone great lengths to to identify state ble levels of participant’s risk for the mal- causes of action that are preempted by ady. To the extent participants that are ERISA, and courts generally been injunction unable to seek an compelling sympathetic to their efforts even ul when coverage, ERISA’s remedial scheme al- is timately finding their preempted. claims entirely illusory. most in example, For Andrews-Clarke v. Trav Co., (D.Mass. F.Supp. elers Ins. that,

The perverse second effect at is 1997), clearly a inveighed: frustrated court same time as inordinately ERISA makes it bring injunction difficult to to enforce a justice, Under traditional notions of - - participant’s rights, in- strong alleged creates if harms true should deny centives for HMOs to in [plaintiff] legal claims bad entitle to remedy some are ac- of benefits received quantity children and her of herself on behalf brought could under ERISA tions that be Greenspring. and against Travelers - 502(a)(1)(B) ... to “recover benefits due breach of her claims just one Consider - plan,” and under the terms of the of action This cause of contract. remedy is duplicating law in state can be enforced promises contractual 514(a). by Regula- It Magna Carta. pre-dates the courts care, conversely, was quality tion notion of very of our bedrock traditionally occupied “a field found be autonomy property and individual at and we did regulation,” id. state precepts the first among It was rights. legislative in the histo- “anything not find in recognized law be the common structure, purpose sug- of ERISA ry, courts of the Commonwealth Congress viewed gesting] by the state zealously guarded has been 502(a)(1)(B) remedy a creating as a to this. Our day from that judiciary injured malprac- by medical participant on it. depends structure capitalist entire tice.” Id. Nevertheless, Court had no choice this case out of the pluck [plaintiffs] but quantity- this explicated further We sought which she redress state court in distinction In re U.S. Health- quality (and litigants relief to other where (3d Cir.1999), care, 193 F.3d available) then, at the behest of alia, concerned, plan participant’s inter a Greenspring, to slam Travelers negligent claim that her HMO was and leave doors her face courthouse presumptively a dis- adopting policy of any remedy. her without 24 hours. charging newborn infants within that the be- “recognize[d] We distinction Id. 52-53. quantity of benefits due under tween exaggeration say It is no plan quality and the of those bene- welfare mightily to struggled courts have federal clear,” id. at always fits will not be expansive fidelity maintain to ERISA’s explained line-drawing that the diffi- avoid- preemption to” clause while “relates “because the culty part arises same partici- foreclosure of ing the wholesale may have assumed both the role as HMO against their causes of action pants’ plan separate and the role administrator for a middle But our search HMOs. provider as a of medical services.” judicial snipe ground proved has newborns after policy discharging hunt, today no closer to success and we are was, however, determined to be a hours ago. This Court’s than we were a decade provider “role as of medical function of the quagmire in illustrate the own decisions “essentially services” because it was themselves. In Dukes which courts find appropriate medical determination (3d Cir.1995), Healthcare, 57 F.3d 350 ..., a certain level of care not a claim that alleging HMO medi- participant sued his and denied.” Id. at requested benefit tort, and cal a state-law malpractice, We therefore held 162-63. preempt- that the claim was argued HMO participant’s squarely claim within “fit[] that the claim was by ed ERISA. We held the class of claims we identified reasoning that ERISA preempted, quality of care” and involving Dukes as the chal- between actions draws a distinction at 163. preempted. was not provided of care lenging quality the impor in our most recent and provided Finally, HMO an claiming those that the decision, Pryz preemption benefits under its tant ERISA inadequate quantity of Healthcare, Inc., v. 245 F.3d plan. challenging actions bowski U.S. explained, As we (3d Cir.2001), allegedly upon harm which federal currently was caselaw re- - by delay approving caused an HMO’s lies quantity quality between deci- by performed to be off-network procedure sions, or eligibility between and treatment - wheth- physicians. question There was no untenable, decisions is and that the blur- itself was er the treatment covered severe, ring becoming is more not less. merely eligibility, namely one of issue was To the extent we insist on categorizing an physician whether off-network could every decision either eligibility HMO as an perform procedure. We took note of decision, or a treatment we contort our- Supreme recent Court’s decision parsing selves into terms that concep- Herdrich, Pegram U.S. 120 tually indistinguishable, and we fail to (2000), 2143, 147 L.Ed.2d 164 where S.Ct. come to terms with the realities of modern distinguished between Court health coverage. eligibility and treatment HMO’s decisions problem This is among evident even rel- Although Pegram directly decisions. con- atively “easy” Pryzbowski cases. per- is fiduciary duty preemp- cerned rather than haps one of the examples clearest-cut of an tion, eligibility-treatment we held that its decision, eligibility for the only HMO’s ac- dichotomy equally applicable in the designing tion was its plan to utilize net- context; indeed, we considered preemption doctors, work a clear matter plan ad- it way viewing quantity- another Conversely, ministration. when one thinks quality distinction. We concluded that an decisions, “treatment” “medical” one eligibility decision is administrative de- physician envisions a and an examination cision, any and that action chal- state-law table, seemingly a world far removed from it lenging partici- because a the HMO’s administrative offices. Yet pant instead suit bring could under ERISA even in it Pryzbowski, takes little creativi- 502(a)(1)(B) “to recover benefits due to ty to recast the “administrative” matter of him plan, under the terms his to enforce plan design as a “treatment” or “medical” rights plan, his the terms of decision, implicitly for the HMO deter- clarify right his future benefits under mined that requiring plan participants to plan.” Conversely, the terms of the physicians see would not expose network treatment decision is a medical decision them to undue risks. It health requires interpretation no itself, impossible and it to characterize decision as preempted by is not 502(a)(1)(B) medical, anything than plaintiff partially since offers a other no directly participants’ avenue of relief. it affected health. Indeed, delay by occasioned B. HMO’s so-called “administrative decision” Dukes, quite literally Pryzbowski’s Ms. I caused believe that In re Health- care, seriously condition to worsen. Pryzbowski rightly were all de- cided, and that opinion today our reaches Supreme recognized itself prec- the correct conclusion based on those dichotomy problem Pegram, this false however, separately, edents. I write (and many possibly where observed that my opinion make clear concern that most) decisions contain elements of HMO extraordinary masks subtleties and com- eligibility both and treatment consider- plexities cry of this area of the law that out ations: or, by Congress, failing for clarification that, fact, many possibly I most cov- great [A] Court. erage simple yes-or-no believe that the fundamental are not questions distinction independent phy- the review is a nevertheless appendicitis like whether questions, (when no dis- to determine there is recommendations condition sicians’ covered has patient appendicitis), they comport with health pute that whether proce- ais covered acupuncture whether requirements. plan’s (when the claim of relief pain dure the im- at bar makes evident The case The more com- unchallenged). is pain can simple rule possibility that such a when-and- question is coverage mon Byzantine complexi- reflect the adequately coverage for Although question. how care. AETNA’S modern-day health ties of and vari- will be clear many conditions (i.e., coverage explicitly equated its policy indisput- will be options treatment ous of medical eligibility) on an assessment still must physicians ably compensable, necessity the medical necessity. But cases. particular to do decide what clause, to convert medical attempts be, one may say, whether The issue decisions, com- eligibility into decisions superior to anoth- option is so treatment I herein. In- problem address pounds circumstances, and needed er under the deed, coverage though even Aetna denied proceed that a decision promptly, so specialized tra- Dr. Picarieflo insisted necessity it would meet the medical critical to DiFelice’s cheostomy tube was terms, In practical requirement.... Tracheotomy extremely seri- health. cannot be un- decisions eligibility these tube, tracheostomy and the procedure, ous judgments tangled physicians’ margin, are described whose uses medical treatment. reasonable about As two integral part procedure.2 of the 228-29, 120 S.Ct. 530 U.S. professors ex- prominent medical school attempted explain courts have Some mul- tracheotomy “is associated with plain, problems “eligibili- away the evident life-threatening com- tiple potentially and dichotomy by holding ty treatment” versus elective conditions.” plications even under employ their own only HMOs which Carrau, Myers and Ricardo L. Eugene N. make medical decisions. physicians can In- Tracheotomy: Early Complications of See, v. Merit e.g., Rubin-Schneiderman Management, and Clinics cidence F.Supp.2d 227 Corp., Behavioral Care (September No. 3 at 589 Chest Medicine (S.D.N.Y.2001). suggest that Such courts 1991). Indeed, with the use of “[e]ven directly employ physi- which do not HMOs surgical techniques, complications optimal in “mixed” decisions engage cannot cians tracheotomy may during pro- occur actually patients. treat they do not because cedure, postoperative pe- in the immediate doubt itself has cast riod, Eugene long surgery.” after the that deci- stating upon explanation, this Stool, Complica- Myers Sylvan N. E. merely “not are “mixed” sions considered Tracheotomy, Tracheotomy 147 tions eligibility are ... treatment because 1985). (Churchill They Livingstone coun- treating person, made the same preventing sel that best means “[t]he Pegram, 530 U.S. at physician.” they [ ] whenever occur complications logically But this distinction is S.Ct. 2143. to detail in paying meticulous attention for an precedent, tenuous even absent that surgery perform- must of the physicians performance no employs HMO (1) prevent aspiration tracheotomy of material purposes of a tube are: trachea 2. The airway hypopharynx. See provide above the tube or in the secure continuation of the Lindholm, Tracheostomy Choice through passage Carl-Eric soft tissues Tube, (Churchill neck; Living- (2) Tracheotomy 125 possibility to offer a of artificial needed; 1985). (3) pressure stone ventilation if seal tracheotomy may as soon as it becomes Aetna’s decision ing largely have been necessary.” procedure suggests perhaps obvious that the is medical that DiFelice’s claim should not preempted. a Such comfortably result would follow under is borne out This assessment Dukes and In re U.S. Healthcare. I agree condition. history of DiFelice’s March Rendell, however, Judge with that Su- diagnosed sleep DiFelice of was preme precedent compels Court con- upper airway His otolar- obstruction. that the proper clusion test is whether a Picariello, yngologist, attempt- Dr. Michael theoretically is possible suit treatments ed several unsuccessful before 502(a), approach an pre- leads to that DiFelice needed a tra- determining emption under the of facts this case. cheostomy surgically tube. Dr. Picariello placed tracheostomy July a tube Judge opinion recognizes Rendell’s that continually it from DiFel- but extubated Aetna’s decision had a medical component. only ice’s neck. It was then that Dr. It declines to characterize it eligi- as either that Picariello determined DiFelice needed treatment, bility or and concludes that in remedy specially-designed po- tube to situations, such mixed preemption turns on tentially life-threatening condition. availability relief under ERISA 502(a). This resolution at least has

Aetna, however, Dr. overruled Picariel- salutary creating bright-line effect of expert judgment medical lo’s deter- rule, perhaps the best we can hope mined that the tube was fact not medi- higher absent intervention from a cally necessary, authori- leaving DiFelice with the ty truly that would enable a injunctive principled option bringing an suit under jurisprudence. But while this rule is rela- paying out-of-pocket ERISA for the tube, tively easy apply, that ease comes at the specially-designed receiving a sec- expense plan participants’ direct wel- standard-shaped ond tube Aetna premise fare. The rule’s HMOs agreed opted to cover. He for the covered tube, employ physicians that do not their own placed, but after it he developed solely business, the insurance progressive a serious and soft tissue and is, they provide not him do care and cannot be bone infection that caused to be ad- medically negligent. In the County opinion’s mitted to hospital Chester in Octo- words, allegation “because there is no ber of following which he was re- care, actually provided Aetna the medical Hospital University ferred to the at the There, judgment Aetna’s use of medical could Pennsylvania. doctors removed only led to eligibility, treat- “significant portions” of his bone and tis- ment, decision.” I infection, believe this state- pectoral sue to treat the and his (with agree) encapsu- ment which I do not surgically reconfigured. muscle was why precisely lates ERISA’s failure to Aetna claims that its decision was not change with the times has rendered merely medical because it was made with incapable of protecting employees, and eye To language. me this why Congress prevent must act to further sense, precisely makes no for Aetna made injustice. the same individualized determination necessity as Dr. Picariello. The C. fact that Aetna is an and Dr. Picar- HMO above, an independent physician entirely existing Supreme iello is As discussed precedent irrelevant to the fundamental character of holds that disal- their My damages assessments. conclusion that lows extracontractual even in in- industry. See Pe the health care faith, nated interpretation of bad

stances 2143; see gram, 530 U.S. deny HMOs that harbor to safe gives Rutter, Democratizing HMO also Kent G. destroying any possibility also claims while “Rule Res the Regulation § un- 502 actions bringing participants Enforce (1996). cue”, 30 Mich. J.L. Ref. U arrangements. contingency fee der treat person’s little role in a Insurers had cases, that, many participants result is - decisions; instead, participant a ment for decisions as law take HMOs’ must hospital, or receive visit a doctor would utilization review Aetna’s example, when treatment, hospital or and the doctor spe- for DiFelice’s coverage denied board If an insurer re the insurer. would bill tube, the tracheostomy he faced cialized bring could pay, participant fused to the pay specialized for the whether to decision to recover ben under ERISA suit appealing whereas out-of-pocket, tube plan. under the terms of efits due impractical in simply decision was HMO’s Congress role envisioned for This was the emergency. such face of a medical well, dis and it worked cases, insight is that the HMO the critical would occur agreement with insurer patient’s actual a de determines facto participant’s medical crisis only after eligibility for ben- along with his treatment abated, system ways and in some had efits, person relatively a rare for it will be much provide an incentive to too created invasive pay procedures who is able than too little. care rather out-of-pocket. changed. Today, approxi- Times have system a creates Because ERISA mately 75% of insured American workers determination fre- which an HMO’s benefit through some receive their health care treatment a determines the actual quently designation type “managed plan, care” receives, directly it follows participant Miller, Andy which includes HMOs. See of care quality determine HMOs Noted, Atlanta J. Managed Savings Care - regardless of make treatment decisions Const., 5, 1997, hall- at E3. One & June actually employ physicians. they whether the uti- managed systems mark care differently, root of courts’ ERISA Put board, approves lization review nightmare is that ERISA preemption coverage procedure for a before denies distinguish eligibil- between forces them to actually place. Although takes procedure while ity providing and treatment decisions may appeal a utilization re- participant that makes the two a remedial structure decision, prior-approval view board’s participants, For virtually synonymous. thought to reduce costs to system is de greater: is still ERISA the torment likely participants HMOs because in control of the places the HMO facto (but approved) proce- inferior choose an receives, yet participant treatment superior procedure for which dure over malprac- preempts any state-law medical out-of-pocket they might ultimately pay provides against tice claim that HMO appeal. an unsuccessful ERISA following com- participant that the can recover no ill-equipped phe- to deal with the is often punitive, wrongful-death pensatory, board, review nomenon of the utilization damages regardless of its malfeasance. lack of remedies available under for the above, actively arisen because encour- This situation has as discussed Because ages deny has failed to evolve to accommo- claims. HMOs HMOs, place which did not even denials now take before date the rise these itself, systematic in 1974. is a when ERISA was enacted treatment effect exist then, quality deterioration of treatment fee-for-service insurers domi- Back receive, participants oxymoronically all oc necessary or appropriate or is investiga- casioned “designed a statute promote experimental” tional or or “in which the the interests of employees and their bene decision as to whether a benefit is covered ficiaries employee benefit plans.” involves a medical judgment.” Shaw, 90, 103 S.Ct. 2890. Put more concretely, had the Act be- law, come Aetna would now possible face

III. compensatory damages but not punitive much, What is to be done? Not absent damages, and its determination of medical by intervention Congress or Supreme the necessity would externally be appealable. Court, for lower courts are bound to follow Although the Act passed House, the it did precedents inexorably lead to the not Senate, survive in the passed which “availability 502 relief’ preemption version of health care reform containing no by test set majority forth the opinion in right to 2990, sue. See H.R. 106th Cong., However, this case. several av- promising (1999). 1st Sess. suggested, As legisla- the enues exist. suggested One is by the Bi- tion approved by the House ap- is one partisan Managed Consensus Care Im- proach. There are doubtless others. provement Act of H.R. 106th Even if Congress act, refuses to howev- Cong., (1999), 1st Sess. passed the er, Court, the Supreme interpretive its House but was watered down the Sen- capacity, is capable of effecting salutary ate. Langbein Wolk, See & Pension and change in many ways. The Court has no Employee Benefit Law at 561-62. That crystal ball, twenty years ago it could Act would have amended by ERISA 514 not have foreseen the radical changes that (e) adding a new subsection providing that have overtaken the health system, care ERISA shall not: and the difficulties that its preemption de- invalidate, construed impair, or cisions would create. The time might be supercede any cause of brought action right to reconsider the string of holdings, by (or a participant beneficiary or the epitomized by Mertens, Russell and estate of a participant beneficiary) or rule out possibility the of recovering com- under State law to recover damages re- pensatory damages ERISA sulting personal injury for 503(a)(3). generally See John H. Lang- wrong against any person death bein, What by ERISA Means “Equitable”: (i) in connection with provision Supreme Trail Court’s Error insurance, services, administrative or Russell, Mertens, Great-West, Yale by services person such to or Law Law, School Center Economics, for a group [plan], health and Public Policy, Research Paper No. (ii) that arises out of arrangement 269, available online at www.ssm.com. by person such provision of Professor Langbein persuasively argues: insurance, such administrative ser- (1) that the Court erred in inter-

vices, or medical services other preting language ERISA’s providing for persons. “other appropriate equitable relief’ The Act would have punitive disallowed mean only relief that traditionally damages when cause of action relates (2) available in courts of equity; and to an “externally appealable decision.” It better view is that Congress intended up set such external appeal procedures for “to remedy wrongs ERISA of the sort denials of benefit claims based on decisions commonly law,” remedied under trust that “the item or service is medically principal law, a core of trust the “make- (1973), 1st Sess. Cong., H.R. 93d plans. “restore[] standard,” attempts

whole (1974). The Senate Rec. 4742 Cong. or she that he position victim to hand, would version, on the other breach been no there had have had would “relate to laws that state of trust.” S. by this Act.” regulated subject matters compensatory what precisely That (1973), 120 Cong., 1st Sess. 93d no there is reason do, and damages (1974). Cong. Rec. to base intended Congress suspect conference, the Com joint final In the omitting while of trusts law on but language, present adopted mittee remedy. I note core law’s predicate only Congress to the full available made it judges among federal alone I am not enacted, and bill was days before the ten to reconsider Supreme Court the urging Metro change. See about the little to said barrier significant has become what Co., at 745 n. 471 U.S. Ins. politan Congressional of realization and the justice Life to reason 2380. There scant Does, F.3d 105 S.Ct. 321 See, e.g., Cicio intent. was resulting language' that J., (Calabresi, believe Cir.2003) dis- (2d 83, 107 deliberative by the entire fully considered Su- late for the (“[I]t too is not senting) to attention indeed, paid who those body; of Error its Trail to retrace preme Court 514(a) provi was opined issue or for beginning, from the start over and cre mandated clean.”). Section sional. slate wipe the Congress Cf. Force to Task Pension a Joint Healthcare, ation of F.2d v. United Corcoran desirability effect and Cir.1992) (“The study practical (5th character- 1321, 1336 Javits, a Senator Jacob preemption, of encompassing relief as equitable of ization that “the said legislation, sponsor plaintiff make the necessary to damages ei at regulation desirability of further with be consistent may well whole - undoubt Federal level State ther the incorporated were principles law trust attention.” edly warrants further interpre- its guide and which into ERISA (remarks (1974) of Sen. 29,942 Cong. Rec. tation.”). Task Force Javits). Unfortunately, for the possibility Another existence, and no further came into never recent trend its Court, given especially forthcoming. regulation §of text beyond the looking toward Congress did suggests The evidence scope, preemptive ERISA’s to determine of scope whether (or carefully consider lack not Congress’s intent reexamine is to de the different reflect thereof) should preemption wel- respect preempting with pension regulation of of federal grees have Many scholars plans. fare benefit Fisk, See plans. benefit welfare plans and carefully con- did Congress noted Language about Last Article it The when scope preemption of of sider the Leg 33 Harv. J. on Preemption?, Fick, ERISA See, The Last e.g., ERISA. drafted 514(a)’s view, my section Pre- is. Language Article about of with sensible scope is 35, 53 broad Legis. preemptive J. on Harv. emption?, 33 law federal plans, for regard pension (1996). would House bill vest provides law and fully displaces state to the “relate laws that state re funding minimum ing, requirements, responsibilities and disclosure reporting employee other a raft of quirements, persons responsibilities fiduciary me, However, it makes safeguards. plans, of’ ERISA-covered on behalf acting to welfare respect sense much less funding and to” that “relate laws state Congress ex- supra, As discussed plans. pension provisions benefits-vesting N.A., Inc., empted benefit welfare plans most of 335-36, 519 U.S. at regulations, ERISA’s substantive (1997) (internal as such omitted). citation Ab- vesting its funding and minimum require- sent guidance textual or meaningful legis- ments. lative history, there is little to prevent a pragmatic problem solution to a Congress it, I unlikely

As it is Congress see has not confronted. intentionally so-called, created “regu- this vacuum,” latory in which it displaced state- No doubt there are other possible solu- regulation law plans welfare benefit tions. however, The vital thing, is that while providing no federal substitute. The either Congress or the Court act quickly, more likely explanation is that Congress because current situation is plainly merely intended to create minimum safe- untenable. Lower courts are routinely guards to protect integrity financial forced to dismiss entirely justified com- plans welfare benefit while stopping short plaints by plan participants who have been of federalizing the regime, entire remedial grievously injured by HMOs and especially light was a what workable sponsors, all ERISA, because of the very system. state-law remedial Congress’s purpose of which was safeguard those failure to distinguish explicitly between very participants. grow Our dockets in- pension and welfare plans benefit in creasingly crowded with cases par- where 514(a) § understandable, for, is as ex- ticipants myriad offer varieties of artful plained above, managed plans care pleadings in desperate their attempts to 514(a) § wreak havoc with as it re- circumvent procrustean reach, ERISA’s lates to welfare benefit plans did not exist and our grows caselaw massively inconsis- when ERISA was enacted. There is no tent due to the sheer complexities of the evidence Congress envisioned the cur- subject and lack of meaningful guid- rent situation. ance. There must be a way. better Taking Congress’s note of understanda- The Clerk of Court is directed to send a lack ble of clairvoyance, (with copy of opinion this attention direct- might pragmatism embrace and lim- concurrence) ed to the to the Solicitor of 514(a)’s §it preemptive scope regarding the Department Labor; of Chair, plans. welfare benefit Although the dis- Member, Ranking Majority Counsel, Chief tinction would support find little in the text and Minority Counsel of the Senate Com- itself, of ERISA Scalia and Justices Gins- Health, Education, mittee on Labor, and burg recently admitted in a concurrence Pensions; Chair, and the Mem- Ranking that: ber, Counsel, Majority Chief and Minority [A]pplying the ‘relate provision to’ ac- Counsel of the House Committee on Edu-

cording to its was a project terms cation and the Workforce. failure, since, doomed to as many a curb- observed, stone philosopher has every- AMBRO, Judge, Circuit concurring. thing is related to everything else. The Judge well-crafted, Rendell’s is opinion statutory provides test, text illusory join I cases, however, it. In many unless the Court willing decree Thus, result underwhelms. Judge like degree pre-emption of that no sensible Becker, I implore for a way - better to make person could have intended which it is these kinds of decisions. not. Division Labor Standards Congress 1974 “a

California passed comprehen of Construction, Dillingham v. sive designed statute promote Enforcement the inter 468 second-guessed providers service beneficiaries their employees ests of preempts ERISA persons, Delta non-medical v. Shaw plans.” benefit employee ERISA, 29 that conflicts law state 85, 90, 103 S.Ct. Lines, 463 U.S. Inc.

Air action 1144(a), “cause of and is a § (1983). U.S.C. That stat 490 2890, 77 L.Ed.2d civil enforcement - scope of within Income Retirement Employee ute 502(a) U.S.C. [29 [ERISA] provisions (“ERISA”), 29 U.S.C. 1974 Act of Security Does, F.3d 321 Cicio ].” compromises policy made seq. § 1001 et Cir.2003) Metropoli- (2d from (quoting 94 rising exponentially to combat in order 58, 66, 481 Taylor, Co. v. Ins. tort tan state melange in a costs health care Life (1987)). In- L.Ed.2d after-the-fact. assessing negligence laws any civil subsection this Frankel, cluded within Medi J. Jonathan generally See [plan] participant “by brought action Care and Health Law Malpractice cal due benefits ... beneficiary recover Lessons Containment: Cost Reformers to enforce plan, his terms of him under Cultures, Yale L.J. Clash plan, the terms of the rights of his forms (1994). the newer Among un- future benefits rights to clarify his healthcare ser providing managing the ” “ 29 U.S.C. plan.... the terms der concur ‘prospectively towas vices colloquially, 1132(a)(1)(B). Stated appropriateness rently assess bene- employee most “federalizes” Elizabeth (quoting at care....’” remedies. fit al., and Growth Change Hoy et W. Aff., Care, Health Winter

Managed case, this Becker in Judges Rendell and 27). dissent partial in his Calabresi Judge out Cicio, point seq., at 106 et F.3d insurers reimburs in 32 of healthcare Instead unsatisfying con- the so-often medical already-given poignantly for ing insureds meaning when cipher use to organizations we structs care, maintenance health re- tort where, “re upon cost containment cultures of (“HMOs”) were created “The preemption. over en clash patient sponsibility each for a fixed fee ceipt of the ex- [,]... spar over in cases these litigants of a terms contract rolled under entity lay financing [the if needed.” provided] tent [is care health specified distinctly Herdrich, to itself appropriated has HMO] 530 gram Pe own substituting its authority by L.Ed.2d medical S.Ct. treating physi- HMOs (2000). expertise contract Physicians (em- Frankel, HMO 103 Yale L.J. at cian.” patients services provide text). calling join the chorus I HMOs, phasis via health fees. for set authority higher set look from employers, a fresh by patients’ purchased Congressional primary better the premiums, promote governing collection “[r]ules - claims, plan par- protecting benefits, of ERISA purpose submission definition “At issue enti over and their beneficiaries. disagreements ticipants and resolution ” of medi- definition less than the Id. at nothing tlement to services.... id., itself,” decision-making line non-routine cal The bottom S.Ct. they after this affects. lives that provided are services medical approved. Sisy- has in concept, system, simple This At the application.

phean frustration costs To save preemption.

forefront where decisions system

a tort

Case Details

Case Name: Difelice v. Aetna U.S. Healthcare

Court Name: Court of Appeals for the Third Circuit

Date Published: Oct 15, 2003

Citation: 346 F.3d 442

Docket Number: 02-3381

Court Abbreviation: 3rd Cir.