Talk:Aetna Health Inc. v. Davila

message: Seriously holy crap I can't understand half of this.  Could someone provide a summary of some sorts at the bottom?
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I appreciate your comment. This entry was written shortly after the CIGNA v. Calad decision and ultimately was the result of perhaps 2 years of research into notable ERISA Supreme Court rulings that had affirmed the fact that insurance plans underwritten by the general operating funds of a private employer could never be held responsible for monetary damages when an adverse decision regarding coverage or lack of coverage caused irreparable harm such as death. CIGNA and Aetna et. al. extended the reach of this impunity to Managed Care decisions by HMO organizations such as CIGNA who administered the health plan for these large multi-state employers. The upshot was and still is that large multistate (now international) Managed Care organizations like CIGNA do not need to be worried about duty of care or negligence in a medical sense.
I hate to put it so bluntly, and this may seem argumentative, and yet by the history of ERISA, Managed Care has License to Kill. A party can try to sue for damages for Managed Care decisions, but what will happen is that the case will be removed to District Court (Federal jurisdiction), and the case will be dismissed on summary judgement because the Federal Law ERISA allows that at best, money paid out of pocket for a denial of a claim can be reimbursed. If a Managed Health decision is wrongfully made and perhaps the person dies, or they are maimed and lose the benefit of income, or any other case for so-called collateral damages, or even if a claim is denied in "bad faith" resulting in the emotional suffering and distress, again, no such relief is possible, so the claim will be dismissed in Federal Court in summary judgment.
I am not a lawyer, but I was a victim of bad faith claim denial. I called a lawyer and asked him what I could do. Basically, he said "nothing." He said it would cost $20,000 to take the case to District Court, and the amount that was denied was under $1000. Lawyers have learned that these cases cannot be won if collateral damages are sought. If you take the case to Small Claims Court, or State Court, where such claims can usually be heard, the Insurance Carrier or Employer will remove the case to Federal Court, where the most they will pay is the amount Insurance should have paid. No lawyer will take a case like this on contingency. So clearly, what incentive does an insurance carrier or HMO have to process claim or manage care in good faith if at worse, the court will rule they have to pay the claim, but if the party dies... well, equitable remedies don't exist for the loss of income, loss of consortium, aggravated negligence. The "make whole" equitable remedy would be to bring the person back to life.
My background was reading all the relevant ERISA Supreme Court Cases plus the US Circuit Cases that the Supreme Court overturned. 
If you are interested in this case, I encourage reading the Supreme Court Case CIGNA v. Calad and the US 5th Circuit Appeals ruling for this case which CIGNA v. Calad overturned, read the record of the oral arguments, and read the opinions of the Supreme Court justices. I tried to document these in the article. And read the applicable ERISA law.
The Supreme Court has long felt its hand were tied on its rulings, however just a case might be, by the wording of the law of ERISA, which was written in the 1970s and never changed. 
One must look too at who were the litigants and who were the respondants in this case. CIGNA v. Calad. CIGNA appealed a case that was won in the 5th US Court of Appeals by Ms Calad.  This tells you how much it would really cost to prevail in a suit against a Managed Care Entity for Malpractice. Ms Calad certainly did not have the money to go this far. The State of Texas was there arguing to uphold its own law. I don't recall that Ms Calad was even represented in the arguments. 
So if the Healthcare industry is willing to appeal a case all the way to the Supreme Court, a case that on its face really does appear that negligence might have been involved, just to continue their immunity to liability to such claims, well, this tells you what the victims of managed care are up against. The main redeeming factor is that government-based insurance plans and church-base insurance plans and individually-paid insurance plans or managed care are not subsumed by ERISA and can and are tried and settled.
I read the oral arguments and the briefs that each party presented their case. Essentially, and this would have to be my opinion, I guess, but CIGNA and Aetna had the best lawyers. They did not necessarily have the best case, but they knew the Supreme Court precedent. And to paraphrase what was said in "Pilot Life Insurance," the congressional intent was "to balance the need for quick and fair claims processing against the risk of discouraging companies from offering insurance at all." Again, the exact wording can be found all over the place. And I find this quote so ironic! Considering that ERISA, when it comes to the Medical Insurance aspect, is all about quick and fair processing of claims, it sounds like what they are saying is, "Congress wrote ERISA so that claims processing was quick and fair... but they didn't want to make it TOO quick or TOO fair, lest employers may be deterred from offering Health Insurance at all.
Well, ERISA again was written in around 1976. So have the federal laws regarding companies of a given size having to offer health care insurance changed since then? If so, I guess the legal gist of "Pilot Life" may be subsumed. Which means a big domino effect of ERISA cases just might fall if this were examined again.
MarySteinborn (talk) 13:31, 4 May 2012 (UTC)
thread_title: Summary?

message: I appreciate your comment. This entry was written shortly after the CIGNA v. Calad decision and ultimately was the result of perhaps 2 years of research into notable ERISA Supreme Court rulings that had affirmed the fact that insurance plans underwritten by the general operating funds of a private employer could never be held responsible for monetary damages when an adverse decision regarding coverage or lack of coverage caused irreparable harm such as death. CIGNA and Aetna et. al. extended the reach of this impunity to Managed Care decisions by HMO organizations such as CIGNA who administered the health plan for these large multi-state employers. The upshot was and still is that large multistate (now international) Managed Care organizations like CIGNA do not need to be worried about duty of care or negligence in a medical sense.
I hate to put it so bluntly, and this may seem argumentative, and yet by the history of ERISA, Managed Care has License to Kill. A party can try to sue for damages for Managed Care decisions, but what will happen is that the case will be removed to District Court (Federal jurisdiction), and the case will be dismissed on summary judgement because the Federal Law ERISA allows that at best, money paid out of pocket for a denial of a claim can be reimbursed. If a Managed Health decision is wrongfully made and perhaps the person dies, or they are maimed and lose the benefit of income, or any other case for so-called collateral damages, or even if a claim is denied in "bad faith" resulting in the emotional suffering and distress, again, no such relief is possible, so the claim will be dismissed in Federal Court in summary judgment.
I am not a lawyer, but I was a victim of bad faith claim denial. I called a lawyer and asked him what I could do. Basically, he said "nothing." He said it would cost $20,000 to take the case to District Court, and the amount that was denied was under $1000. Lawyers have learned that these cases cannot be won if collateral damages are sought. If you take the case to Small Claims Court, or State Court, where such claims can usually be heard, the Insurance Carrier or Employer will remove the case to Federal Court, where the most they will pay is the amount Insurance should have paid. No lawyer will take a case like this on contingency. So clearly, what incentive does an insurance carrier or HMO have to process claim or manage care in good faith if at worse, the court will rule they have to pay the claim, but if the party dies... well, equitable remedies don't exist for the loss of income, loss of consortium, aggravated negligence. The "make whole" equitable remedy would be to bring the person back to life.
My background was reading all the relevant ERISA Supreme Court Cases plus the US Circuit Cases that the Supreme Court overturned. 
If you are interested in this case, I encourage reading the Supreme Court Case CIGNA v. Calad and the US 5th Circuit Appeals ruling for this case which CIGNA v. Calad overturned, read the record of the oral arguments, and read the opinions of the Supreme Court justices. I tried to document these in the article. And read the applicable ERISA law.
The Supreme Court has long felt its hand were tied on its rulings, however just a case might be, by the wording of the law of ERISA, which was written in the 1970s and never changed. 
One must look too at who were the litigants and who were the respondants in this case. CIGNA v. Calad. CIGNA appealed a case that was won in the 5th US Court of Appeals by Ms Calad.  This tells you how much it would really cost to prevail in a suit against a Managed Care Entity for Malpractice. Ms Calad certainly did not have the money to go this far. The State of Texas was there arguing to uphold its own law. I don't recall that Ms Calad was even represented in the arguments. 
So if the Healthcare industry is willing to appeal a case all the way to the Supreme Court, a case that on its face really does appear that negligence might have been involved, just to continue their immunity to liability to such claims, well, this tells you what the victims of managed care are up against. The main redeeming factor is that government-based insurance plans and church-base insurance plans and individually-paid insurance plans or managed care are not subsumed by ERISA and can and are tried and settled.
I read the oral arguments and the briefs that each party presented their case. Essentially, and this would have to be my opinion, I guess, but CIGNA and Aetna had the best lawyers. They did not necessarily have the best case, but they knew the Supreme Court precedent. And to paraphrase what was said in "Pilot Life Insurance," the congressional intent was "to balance the need for quick and fair claims processing against the risk of discouraging companies from offering insurance at all." Again, the exact wording can be found all over the place. And I find this quote so ironic! Considering that ERISA, when it comes to the Medical Insurance aspect, is all about quick and fair processing of claims, it sounds like what they are saying is, "Congress wrote ERISA so that claims processing was quick and fair... but they didn't want to make it TOO quick or TOO fair, lest employers may be deterred from offering Health Insurance at all.
Well, ERISA again was written in around 1976. So have the federal laws regarding companies of a given size having to offer health care insurance changed since then? If so, I guess the legal gist of "Pilot Life" may be subsumed. Which means a big domino effect of ERISA cases just might fall if this were examined again.
MarySteinborn (talk) 13:31, 4 May 2012 (UTC)
thread_title: =

message: I propose that Cigna Healthcare of Texas, Inc. v. Calad ("Calad") be merged into this article ("Davila"). Calad (Docket No. 03-83) and Davila (Docket No. 02-1845) were consolidated and were both decided by the Supreme Court in the Davila opinion. See the Davila syllabus at Justia: "Together with No. 03–83, CIGNA HealthCare of Texas, Inc., dba CIGNA Corp. v. Calad et al., also on certiorari to the same court." The facts of the Calad case can be incorporated into a "background" or "procedural history" heading in the Davila article. There are also citations needed and potential POV issues, but merging the articles can be followed by other revisions. LegalSkeptic (talk) 13:40, 23 January 2019 (UTC)
replies: text: Support. GregJackP Boomer!  00:29, 6 August 2019 (UTC)
replies: text:  Klbrain (talk) 20:40, 11 April 2020 (UTC)
thread_title:  Merger proposal