Opinion ID: 168322
Heading Depth: 2
Heading Rank: 1

Heading: Preemption of state-law claims

Text: W e begin by addressing whether the Linds’ state-law claims are barred by ERISA , which preempts all state laws that “relate to” employee benefit plans. 29 U.S.C. § 1144(a). It is undisputed that the Linds’ original claims are based on state law and that Aetna’s plan is an employee benefit plan; the issue is whether the claims “relate to” the A etna plan. This court reviews the district court’s determination of preemption de novo. Airparts Co. v. Custom Benefit Servs. of Austin, Inc., 28 F.3d 1062, 1064 (10th Cir. 1994). Both the language of the statute and its legislative history indicate that Congress intended ERISA to sw eep with broad force. The Act’s stated purpose is to protect the participants in employee benefit plans by “providing for -4- appropriate remedies, sanctions, and ready access to the Federal courts.” 29 U.S.C. § 1001(b). The conference report shows that such language was intended to parallel that of the Labor-M anagement Relations Act of 1947, which “pre-empts any ‘state-law claim [whose resolution] is substantially dependent upon the analysis of the terms of an agreement made between the parties in a labor contract.’” Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 55 (1987) (quoting Allis-Chalmers Corp. v. Lueck, 471 U.S. 202, 220 (1985)). As a result, the Supreme Court has found ERISA to preempt nearly all state claims relating to causes of action against covered health insurers, even when “the elements of the state cause of action [do] not precisely duplicate the elements of an ERISA claim.” Davila, 542 U.S. at 216. Appellants face an unenviable task in distinguishing their case from Davila, in which the Supreme Court found preemption on similar claims and nearly identical facts. Juan Davila’s treating physician prescribed Vioxx to remedy M r. Davila’s arthritis, but Aetna refused to authorize payment until M r. Davila tried a “step drug,” Naprosyn, first. Davila, 542 U.S. at 205; Roark v. Humana, Inc., 307 F.3d 298, 303 (5th Cir. 2002). W hen M r. Davila began taking Naprosyn, he suffered a severe reaction that required extensive treatment and hospitalization. Davila, 542 U.S. at 205. He brought claims to recover his medical costs against Aetna under the Texas Health Care Liability Act, which provided for broader remedies than did ERISA. Id. The Court held that M r. -5- Davila’s claims were entirely pre-empted: “[A]ny state-law cause of action that duplicates, supplements, or supplants the ERISA civil enforcement remedy conflicts with the clear congressional intent to make the ERISA remedy exclusive and is therefore pre-empted.” Id. at 209. The Linds make several attempts to distinguish their case from Davila, none of which we find persuasive. First, they argue that this case is distinct because, rather than deny coverage within the plan’s rules, Aetna misapplied, or “acted outside of” the plan when it did not follow appropriate notification procedures in declining to renew M r. Lind’s prescription. That, however, is a distinction without a difference. Davila is clear that ERISA applies whenever “respondents complain . . . about denials of coverage promised under the terms of ERISA -regulated employee benefit plans,” or “to rectify a wrongful denial of benefits.” Id. at 211, 214. The language of ERISA itself makes clear that it includes civil actions “to recover benefits due . . . under the terms of [the] plan.” 29 U.S.C. § 1132(a)(1)(B). ERISA applies to denials of coverage that are either proper under the plan’s rules or improper under the plan’s rules. Appellants also argue that their claims for medical negligence and respondeat superior are outside the scope of Davila. They claim that a Dr. Jane Doe, employed by Aetna, “made the determination that Ritalin rather than Provigil was the appropriate drug to treat Lind’s M S. Aetna then imposed this determination upon Lind’s treating physician.” Appellants’ Br. 10. In support of -6- this claim, the Linds cite Pacificare of Oklahoma, Inc. v. Burrage, 59 F.3d 151 (10th. Cir 1995), in which a patient sued his doctor for medical malpractice and included a claim for respondeat superior against the doctor’s employer, a health maintenance organization. Id. at 153. The Pacificare Court found for the plaintiff, holding that respondeat superior claims against insurer-employers for medical malpractice survive ERISA. Id. at 155. Pacificare carves out a very narrow exception, however. The Court made clear that its holding was based on the fact that “the present claim does not involve the administration of benefits or the level or quality of benefits promised by the plan; the claim alleges negligent care by the doctor and an agency relationship between the doctor and the HM O.” Id. This type of claim arises “when an HM O plan elects to directly provide medical services or leads a participant to reasonably believe that it has, rather than simply arranging and paying for treatment.” Id. (quoting Haas v. Group Health Plan, Inc., 875 F.Supp. 544, 548 (S.D. Ill. 1994)). Such is not the case here. Dr. Jane Doe was not acting as a treating physician, nor is M r. Lind alleging medical negligence against his actual treating physician, Dr. G onzalez. M oreover, there is no agency relationship between Dr. Gonzalez – an outside provider – and Aetna for the purposes of prescribing medication. In fact, the Linds’ claims are specifically precluded by the language of Pacificare itself, which allows for claims only where “the administration of benefits” is not -7- involved. Id. Appellants’ medical negligence claim is unavoidably linked to, and is therefore preempted by, ER ISA.