Liability for managed care decisions: The Employee Retirement Income Security Act (ERISA) and the uneven playing field

American Journal of Public Health

Volumn 86, Issue 6, 1996, Pages 863-869

  Mariner, Wendy K ^a  

^a BOSTON UNIVERSITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

HEALTH CARE POLICY; HEALTH INSURANCE; MALPRACTICE; MEDICAL DECISION MAKING; MEDICAL LIABILITY; RETIREMENT; REVIEW;

EID: 0029894478     PISSN: 00900036     EISSN: None     Source Type: Journal    
DOI: 10.2105/AJPH.86.6.863     Document Type: Review

References (68)

1. Corcoran v. United HealthCare, Inc, 965 F2d 1321 (9th Cir), cert denied, 113 SCt 812 (1992).
2. Employee Retirement Income Security Act of 1974, 29 USC 1001-1461.
3. McCandless v McWha, 22 Pa (10 Harris) 261 (1853).
4. Kelley v Rossi, 395 Mass 659 (1985).
5. Bull Shoals Community Hospital v Partee, 310 Ark 98 (1992).
6. Boyd v Albert Einstein Medical Center, 377 Pa Super Ct 609 (1988).
7. Kapp v Ballantine, 380 Mass 186 (1980).
8. Darling v Charlestown Community Memorial Hospital, 33 III 2d 326 (1965).
9. Wilson v Blue Cross of Southern California, 222 Cal App 3d 660, 271 Cal Rptr 876 (1990).
10. Robbins v HIP of New Jersey, 264 NJ Super 572 (1993).
11. Sloan v Metropolitan Health Council of Indianapolis, Inc, 516 NE2d 1104 (Ind Ct App 1987).
12. Hannola v Lakewood, 68 Ohio App 2d 61 (1980).
13. Blum JD. An analysis of legal liability in health care utilization review and case management. Houston L Rev. 1989;26:191-228.
14. Chase v Independent Practice Association, Inc. 31 Mass App Ct 661 (1991).
15. Kaiser Foundation Health Plan of Colorado, Inc v Evans, 1995 Colo LEXIS 570 (1995).
16. Cannon v Lane, 867 P2d 1235 (Okla 1993) (finding that a binding arbitration requirement in an HMO contract was void because it violated the state arbitration statute).
17. Madden v Kaiser Foundation Hospitals, 17 Cal 3d 699 (1976) (upholding the state employer's authority to act as an agent for enrollees to agree to binding arbitration in contract with the HMO).
18. Gold MR, Hurley R, Lake T, Ensor T, Berenson R. A national survey of the arrangements managed-care plans make with physicians. New Engl J Med. 1995;333:1678-1683.
19. Mariner WK. Business v medical ethics: conflicting standards for managed care. J Law Med Ethics. 1995;23:236-246.
20. HR Rep No. 93-533, 93rd Cong, 2d Sess, Oct 2, 1973, reprinted in US Cong Code & Admin News, 4639-4670.
21. 29 USC 1144(a).
22. FMC Corp v Holliday, 498 US 52 (1990).
23. 29 USC 1002.
24. Moore v Metropolitan Life Insurance Co, 856 F2d 488 (2d Cir 1988).
25. Young v Standard Oil (Indiana), 849 F2d 1039 (7th Cir), cert denied, 109 SCt 529 (1988).
26. Shaw v Delta Air Lines, Inc, 463 US 85, 91 (1983).
27. Ingersoll-Rand v McClendon, 498 US 133 (1990).
28. Pilot Life Insurance Co v Dedeaux, 481 US 41 (1987).
29. ERISA, §502(a)(1)(B), 29 USC 1132(a) (1)(B).
30. Mertens v Hewitt Associates, 113 SCt 2063 (1993).
31. O'Neil P. Protecting ERISA health care claimants: practical assessment of a ne-glected issue in health care reform. Ohio St L J. 1994;55:723-780.
32. Massachusetts Mutual Life Insurance Co v Russell, 473 US 134, 146, 147 (1985).
33. Kuhl v Lincoln National Health Plan of Kansas City; Inc, 999 F2d 298 (8th Cir 1993), cert denied, 114 SCt 694 (1994).
34. Spain v Aetna Life Insurance Co, 11 F3d 129 (9th Cir 1993), cert denied, 114 SCt 1612 (1994).
35. Tolton v American Biodyne, Inc, 48 F3d 937 (6th Cir Mar 3, 1995).
36. Keamey v US Healthcare, Inc, 859 F Supp 182 (1994).
37. Butler v Wu, 853 F Supp 125 (D NJ 1994).
38. Nealy v US Healthcare HMO, 844 F Supp 966 (SD NY 1994).
39. Ricci v Gooberman, 840 F Supp 316 (D NJ 1993).
40. Pomeroy v Johns Hopkins Medical Services, Inc, 868 F Supp 110 (D Md 1994).
41. Bailey-Gates v Aetna Life Insurance Co, 890 F Supp 73 (D Conn 1994).
42. Dukes v US Health Care Systems of Pennsylvania, Inc, 848 F Supp 39 (ED Pa 1994), and Visconti ex rel Visconti v US Healthcare, 857 F Supp 1097 (ED Pa 1994), both reversed by Dukes v US Healthcare, Inc, 57 F3d 350 (3d Cir June 19,1995), cert denied, 116 SCt 564 (1995).
43. Whelan v Keystone Health Plan East, 1995 US Dist LEXIS 9417 (ED Pa 1995).
44. Jackson v Roseman, 878 F Supp 820 (D Md 1995).
45. Nealy v US Healthcare HMO, 844 F Supp 966 (SD NY 1994).
46. Haas v Group Health Plan, Inc, 875 F Supp 544 (SD III 1994).
47. Dearmas v Av-Med, Inc, 865 F Supp 816 (SD Fla 1004).
48. Burke v Smithkline Bio-Science Labs, 858 F Supp 1181 (MD Fla 1994).
49. Paterno v Albueme, 855 F Supp 1263 (SD Fla 1994).
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51. Elsesser v Hospital of Philadelphia College of Osteopathic Medicine, 802 F Supp 1286 (ED Pa 1992).
52. Dukes v US Healthcare, Inc, 57 F3d 350 (3d Cir June 19, 1995), cert denied, 1995 116 SCt 564 (1995).
53. The Third Circuit also reversed the same district court's decision in Visconti ex rel Visconti v US Health Care, 857 F Supp 1097 (ED Pa 1994), which was consolidated with the Dukes case on appeal. Ronald Visconti claimed that an ERISA HMO was vicariously liable for its physician's malpractice resulting in the death of his pregnant wife.
54. The court of appeals reversed the district court decision. The case was to be remanded to the state court, which could determine, after hearing the facts of the case, whether Dukes' claims were preempted by ERISA.
55. Dukes at 356, quoting §502(a)(1)(B) of ERISA, 29 USC 1132(a)(1)(B).
56. Pacificare of Oklahoma, Inc v Burrage, 59 F3d 151 (10th Cir July 11, 1995). After this article was written, the Tenth Circuit relied on Pacificare to find that ERISA did not preempt a claim that an HMO was vicariously liable for its agent/physicians' failure to detect a malignant lesion. Prudential Health Care Plan Inc v Lewis, 1996 US App LEXIS 2529 (10th Cir Feb 21, 1996).
57. Id, citing Airparts Co v Custom Benefit Services of Austin Inc, 28 F3d 1062, 1064-1065 (10th Cir 1994), and National Elevator Industries, Inc v Calhoon, 957 F2d 1555, 1558-1559 (10th Cir), cert denied, 113 SCt 406 (1992).
58. Rice v Panchal, 65 F3d 637 (7th Cir Sept 12, 1995).
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60. New York State Conference of BlueCross & BlueShield Plans v Travelers Insurance Co, 115 SCt 1671 (1995).
61. The Court did not describe the types of laws (other than rate regulation) that might be saved from ERISA preemption because that issue was not before it. ERISA preemption has greatly circumscribed states' options for legislative reform to expand or regulate health insurance coverage. See Chirba-Martin MA, Brennan TA. The critical role of ERISA in state health reform. Health Aff. 1994;13:142-156;
62. The Court did not describe the types of laws (other than rate regulation) that might be saved from ERISA preemption because that issue was not before it. ERISA preemption has greatly circumscribed states' options for legislative reform to expand or regulate health insurance coverage. See Chirba-Martin MA, Brennan TA. The critical role of ERISA in state health reform. Health Aff. 1994;13:142-156; and Mariner WK. Problems with employer-provided health insurance - the Employee Retirement Income Security Act and health care reform. N Engl J Med. 1992;327:1682-1685.
63. Mackey v Lanier Collection Agency & Service, Inc, 486 US 825 (1988).
64. Pilot Life, 481 US at 44 (citing 29 USC 1001(b)).
65. Congressional Record 1994; 120:29,
66. quoted by Brennan J, concurring in Massachusetts Mutual Life Insurance Co v Russell, 473 US 134, 156 (1985).
67. Zanglein JE. Closing the gap: safeguarding participants' rights by expanding the federal common law of ERISA. Wash U L Q. 1994;72:671-723.
68. Carr WK, Liebross RL. Wrongs without rights: the need for a strong federal common law of ERISA. Stan L Pol'y Rev. 1992/93;4:221-232.