Source: https://case-law.vlex.com/vid/542-u-s-200-605757926
Timestamp: 2019-04-20 01:10:58+00:00

Document:
Party Name: AETNA HEALTH INC., FKA AETNA U. S. HEALTHCARE INC. AND AETNA U. S. HEALTHCARE OF NORTH TEXAS INC., PETITIONER v. JUAN DAVILA CIGNA HEALTHCARE OF TEXAS, INC., DBA CIGNA CORPORATION, PETITIONER v. RUBY R. CALAD ET AL.
RUBY R. CALAD ET AL.
[124 S.Ct. 2490] Syllabus [*] Respondents brought separate Texas state-court suits, alleging that petitioners, their health maintenance organizations (HMOs), had refused to cover certain medical services in violation of an HMO's duty "to exercise ordinary care" under the Texas Health Care Liability Act (THCLA), and that those refusals "proximately caused" respondents' injuries. Petitioners removed the cases to federal courts, claiming that the actions fit within the scope of, and were thus completely pre-empted by, § 502 of the Employee Retirement Income Security Act of 1974 (ERISA). The District Courts agreed, declined to remand the cases to state court, and dismissed the complaints with prejudice after respondents refused to amend them to bring explicit ERISA claims. Consolidating these and other cases, the Fifth Circuit reversed. It found that respondents' claims did not fall under ERISA § 502(a)(2), which allows suit against a plan fiduciary for breaches of fiduciary duty to the plan, because petitioners were being sued for mixed eligibility and treatment decisions that were not fiduciary in nature, see Pegram v. Herdrich, 530 U.S. 211, 120 S.Ct. 2143, 147 L.Ed.2d 164; and did not fall within the scope of § 502(a)(1)(B), which provides a cause of action for the recovery of wrongfully denied benefits, because THCLA did not duplicate that cause of action, see Rush Prudential HMO, Inc. v. Moran, 536 U.S. 355, 122 S.Ct. 2151, 153 L.Ed.2d 375.
Respondents' state causes of action fall within ERISA § 502(a)(1)(B), and are therefore completely pre-empted by ERISA § 502 and removable to federal court. Pp. 2494-2502.
action that duplicates, supplements, or supplants ERISA's civil enforcement remedy conflicts with clear congressional intent to make that remedy exclusive, and is therefore pre-empted. ERISA § 502(a)'s pre-emptive force is still stronger. Since ERISA § 502(a)(1)(B)'s pre-emptive force mirrors that of § 301 of the Labor Management Relations Act, 1947, Metropolitan Life Ins. Co. v. Taylor, 481 U.S. 58, 65-66, 107 S.Ct. 1542, 95 L.Ed.2d 55, and since § 301 converts state causes of actions into federal ones for purposes of determining the propriety of removal, so too does ERISA § 502(a)(1)(B). Pp. 2494-2496.
(b) If an individual, at some point in time, could have brought his claim under ERISA § 502(a)(1)(B), and where no other independent legal duty is implicated by a defendant's actions, then the individual's cause of action is completely pre-empted by ERISA § 502(a)(1)(B). Respondents brought suit only to rectify wrongful benefits denials, and their only relationship with petitioners is petitioners' partial administration of their ERISA-regulated benefit plans; respondents therefore could have brought § 502(a)(1)(B) claims to recover the allegedly wrongfully denied benefits. Both respondents allege violations of the THCLA's duty of ordinary care, which they claim is entirely independent of any ERISA duty or the employee benefits plans at issue. However, respondents' claims do not arise independently of ERISA or the plan terms. If a managed care entity correctly concluded that, under the relevant plan's terms, a particular treatment was not covered, the plan's failure to cover the requested treatment would be the proximate cause of any injury arising from the denial. More significantly, the THCLA provides that a managed care entity is not subject to THCLA liability if it denies coverage for a treatment not covered by the plan it administers. Pp. 2496-2498.
did this Court suggest that ERISA § 502(a)'s pre-emptive force is limited to state causes of action that precisely duplicate an ERISA § 502(a) cause. Nor would it be consistent with this Court's precedent to do so. Pp. 2498-2500.
Pilot Life, 481 U.S., at 52, 107 S.Ct. 1549. Allowing respondents to proceed with their state-law suits would "pose an obstacle" to that objective. Ibid. P. 2500.
(e) Pegram's holding that an HMO is not intended to be treated as a fiduciary to the extent that it makes mixed eligibility decisions acting through its physicians is not implicated here because petitioners' coverage decisions are pure eligibility decisions. A benefit determination under ERISA is part and parcel of the ordinary fiduciary responsibilities connected to the administration of a plan. That it is infused with medical judgments does not alter this result. Pegram itself recognized this principle, see 530 U.S., at 231-232, 120 S.Ct. 2143. And ERISA and its implementing regulations confirm this interpretation. Here, petitioners are neither respondents' treating physicians nor those physicians' employees. Pp. 2500-2502.
307 F.3d 298, reversed and remanded.
THOMAS, J., delivered the opinion for a unanimous Court. GINSBURG, J., filed a concurring opinion, in which BREYER, J., joined, post, p. 2503.
James A. Feldman, for the United States as amicus curiae, by special leave of the Court, supporting the petitioners.
David C. Mattax, for Texas, et al., as amici curiae, by special leave of the Court.
John B. Shely, Kendall M. Gray, Andrews & Kurth LLP, Houston, Texas, Roy T. Englert, Jr., Robbins, Russell, Englert, Orseck & Untereiner LLP, Washington, D.C., Miguel A. Estrada, Counsel of Record, Mark A. Perry, William M. Jay, Gibson, Dunn & Crutcher LLP, Washington, D.C., J. Edward Neugebauer, Aetna Health Inc., Blue Bell, PA, for Petitioner.
Elizabeth Sturdivant Kerr, Fort Worth, TX, Eric Schnapper William, Gates Hall School of Law, University of Washington, Seattle, WA, George Parker Young, Counsel of Record, Tylene K. Di, Sciullo Law Offices of George Parker Young, P.C., Fort Worth, TX, for Respondents.
Robert N. Eccles, Counsel of Record, Jonathan D. Hacker, Alissa M. Starzak, O'Melveny & Myers LLP, Washington, D.C., for Petitioner CIGNA HealthCare of Texas, Inc.
In these consolidated cases, two individuals sued their respective health maintenance organizations (HMOs) for alleged failures to exercise ordinary care in the handling of coverage decisions, in violation of a duty imposed by the Texas Health Care Liability Act (THCLA), Tex. Civ. Prac. & Rem.Code Ann. §§ 88.001-88.003 (West 2004 Supp. Pamphlet). We granted certiorari to decide whether the individuals' causes of action are completely pre-empted by the "interlocking, interrelated, and interdependent remedial scheme," [124 S.Ct. 2493] Massachusetts Mut. Life Ins. Co. v. Russell, 473 U.S. 134, 146, 105 S.Ct. 3085, 87 L.Ed.2d 96 (1985), found at § 502(a) of the Employee Retirement Income Security Act of 1974 (ERISA), 88 Stat. 891, as amended, 29 U.S.C. § 1132(a) et seq. 540 U.S. 981, 124 S.Ct. 462, 463, 157 L.Ed.2d 370 (2003). We hold that the causes of action are completely pre-empted and hence removable from state to federal court. The Court of Appeals, having reached a contrary conclusion, is reversed.

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