Document: 542 U.S. 200 AETNA HEALTH INC., FKA U. S. HEALTHCARE ET AL.v.DAVILA No. 02-1845. Supreme Court of United States. Argued March 23, 2004. Decided June 21, 2004.* Respondents brought separate Texas state-court suits, alleging that petitioners, their health maintenance organizations (HMOs), had refused to cover certain medical services in violation an HMO's duty "to exercise ordinary care" under the Health Care Liability Act (THCLA), and those refusals "proximately caused" respondents' injuries. Petitioners removed cases federal courts, claiming actions fit within scope of, were thus completely pre-empted by, § 502 Employee Retirement Income Security 1974 (ERISA). The District Courts agreed, declined remand state court, dismissed complaints with prejudice after respondents amend them bring explicit ERISA claims. Consolidating these other cases, Fifth Circuit reversed. It found claims did not fall 502(a)(2), which allows suit against a plan fiduciary for breaches plan, because petitioners being sued mixed eligibility treatment decisions nature, see Pegram v. Herdrich, 530 211; 502(a)(1)(B), provides cause action recovery wrongfully denied benefits, THCLA duplicate action, Rush Prudential HMO, Inc. Moran, 536 355. Held: Respondents' causes are therefore by removable court. Pp. 207-221. (a) When statute pre-empts state-law claim can be removed. See Beneficial Nat. Bank Anderson, 539 1, 8. is such statute. Because its purpose provide uniform regulatory regime, includes expansive pre-emption provisions, as 502(a)'s integrated enforcement mechanism, intended ensure employee benefit regulation "exclusively concern," Alessi Raybestos-Manhattan, Inc., 451 504, 523. Any duplicates, supplements, or supplants ERISA's civil remedy conflicts clear congressional intent make exclusive, pre-empted. pre-emptive force still stronger. Since 502(a)(1)(B)'s mirrors 301 Labor Management Relations Act, 1947, Metropolitan Life Ins. Co. Taylor, 481 58, 65-66, since converts into ones purposes determining propriety removal, so too does 502(a)(1)(B). 207-209. (b) If individual, at some point time, could have his where no independent legal implicated defendant's actions, then individual's only rectify wrongful benefits denials, relationship petitioners' partial administration ERISA-regulated plans; 502(a)(1)(B) recover allegedly benefits. Both allege violations THCLA's care, they entirely any plans issue. However, do arise independently terms. managed care entity correctly concluded that, relevant plan's terms, particular was covered, failure requested would proximate injury arising from denial. More significantly, subject liability if it denies coverage covered administers. 210-214. (c) Circuit's reasons reaching contrary conclusion all erroneous. First, significant asserted tort, rather than contract, seeking reimbursement denied. distinguishing between non-pre-empted based on label affixed allow parties evade simply relabeling contract tortious breach contracts. And fact attempts authorize remedies beyond 502(a) authorizes put outside mechanism. See, e.g., Pilot Dedeaux, 41, 43. Second, court believed plans' wording immaterial invoked external duty, but material creates rights respective plans. Finally, nowhere this suggest limited precisely cause. Nor consistent Court's precedent so. 214-216. (d) Also unavailing argument law regulating insurance saved 514(b)(2)(A). This understanding 514(b)(2)(A) informed overpowering policy embodied 502(a), create exclusive remedy, Life, S., 52. Allowing proceed suits "pose obstacle" objective. Ibid. 216-218. (e) Pegram's holding HMO treated extent makes acting through physicians here pure decisions. A determination part parcel responsibilities connected plan. That infused judgments alter result. itself recognized principle, 231-232. implementing regulations confirm interpretation. Here, neither treating nor physicians' employees. 218-221. 307 F. 3d 298, reversed remanded. THOMAS, J., delivered opinion unanimous Court. GINSBURG, filed concurring opinion, BREYER, joined, post, p. 222. CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR FIFTH CIRCUIT. Miguel A. Estrada argued both cases. With him briefs 02-1845 Mark Perry, J. Edward Neugebauer, John B. Shely, Kendall M. Gray, Roy T. Englert, Jr. On 03-83 Robert N. Eccles Jonathan D. Hacker. James Feldman States amicus curiae urging reversal. brief Acting Solicitor General Clement, Deputy Kneedler, Howard Radzely, Allen H. Feldman, Nathaniel I. Spiller, Sieger. David Mattax, Assistant Attorney Texas, State et al. amici affirmance. Greg Abbott, General, Barry R. McBee, First Burbach, Ted Cruz, Rance L. Craft Kristofer Monson, Solicitors Anabelle Rodríguez, Secretary Justice Puerto Rico, Attorneys follows: Bill Lockyer California, Richard Blumenthal Connecticut, Jane Brady Delaware, Lisa Madigan Illinois, Phill Kline Kansas, Charles C. Foti, Jr., Louisiana, Joseph Curran, Maryland, Mike Hatch Minnesota, Jeremiah W. "Jay" Nixon Missouri, McGrath Montana, Brian Sandoval Nevada, Patricia Madrid New Mexico, Eliot Spitzer York, Jim Petro Ohio, Drew Edmondson Oklahoma, Hardy Myers Oregon, Shurtleff Utah, William Sorrell Vermont, Christine O. Gregoire Washington. George Parker Young Eric Schnapper.† JUSTICE THOMAS 1 In consolidated two individuals (HMOs) alleged failures handling decisions, imposed Tex. Civ. Prac. & Rem. Code Ann. §§ 88.001-88.003 (West 2004 Supp. Pamphlet). We granted certiorari decide whether individuals' "interlocking, interrelated, interdependent remedial scheme," Massachusetts Mut. Russell, 473 134, 146 (1985), (ERISA), 88 Stat. 891, amended, 29 1132(a) seq. 540 981 (2003). hold hence Appeals, having reached conclusion, 2 * 3 Respondent Juan Davila participant, respondent Ruby Calad beneficiary, Their sponsors entered agreements Aetna CIGNA Healthcare administer Under Davila's instance, reviews requests pays providers, doctors, hospitals, nursing homes, perform members; Calad's sponsor's agreement, responsible 4 suffered injuries Aetna's CIGNA's recommended physicians. physician prescribed Vioxx arthritis pain, pay it. appeal contest decision, he purchase own resources seek reimbursement. Instead, began taking Naprosyn, severe reaction required extensive hospitalization. underwent surgery, although her extended hospital stay, discharge nurse determined meet criteria continued stay. consequently experienced postsurgery complications forcing return hospital. She alleges occurred approved longer 5 petitioners. Invoking 88.002(a), refusal violated "duty when making decisions," Federal Courts, arguing 502(a). claims, prejudice. B 6 appealed Appeals several others raising similar issues. "duplicat[e] fal[l] remedy" Roark Humana, 305 (2002) (internal quotation marks omitted). After examining available possibly two: 7 Analyzing 502(a)(2) first, 211 (2000), "mixed decisions" nature. 3d, 307-308.1 next scope. "assert tort claims," while "creates contract," id., 309, also "are them," request "tort damages" "an external, statutorily `ordinary care,'" ibid. From 355 (2002), derived principle complete situations "States . listed 502(a)," "[b]ecause collecting benefits," fell 310-311. II 8 removal statute, "any district courts original jurisdiction, may defendant" 28 1441(a). One category jurisdiction "[f]ederal question" cases: "arising Constitution, laws, treaties States." 1331. face issue law. 9 Ordinarily, case arises turns "`well-pleaded complaint'" rule. Franchise Tax Bd. Cal. Construction Laborers Vacation Trust Southern Cal., 463 9-10 (1983). has explained 10 "whether one Constitution treaty States, sense jurisdictional statute[,] must what necessarily appears plaintiff's statement bill declaration, unaided anything anticipation avoidance defenses thought defendant interpose." Taylor 234 74, 75-76 (1914). 11 particular, existence defense normally statutory under" Louisville Nashville Mottley, 149 (1908), "a [generally] remove unless complaint establishes `arises under' law." Bd., supra, 10. There exception, however, well-pleaded "[W]hen wholly displaces pre-emption," "[w]hen comes even pleaded terms law, reality statutes. 12 Congress enacted "protect interests participants beneficiaries" setting out substantive requirements "provid[e] appropriate remedies, sanctions, ready access courts." 1001(b). regime over To end, 514, 1144, concern." 523 (1981). 13 "comprehensive legislative scheme" system procedures enforcement." 147 1132(a), distinctive feature ERISA, essential accomplish Congress' creating comprehensive As said 41 (1987): 14 "[T]he detailed provisions set forth scheme represents careful balancing need prompt fair settlement public interest encouraging formation choices reflected inclusion exclusion undermined ERISA-plan beneficiaries free obtain rejected ERISA. `The six carefully finally strong evidence intend forgot incorporate expressly.'" Id., 54 (quoting 146). 15 Therefore, 54-56; Ingersoll-Rand McClendon, 498 133, 143-145 (1990). 16 65-66 (1987), similarity language used 1947 (LMRA), combined "clear intention" questions like manner LMRA," established mirrored LMRA 301. Avco Corp. Machinists, 390 557 (1968), Thus, mechanism "extraordinary power" "converts common stating rule." 65-66. Hence, "causes [are] court." 66. III 17 provides: 18 "A — (1) participant beneficiary (B) due enforce clarify future plan." 1132(a)(1)(B). 19 provision relatively straightforward. believes promised provided, generically "enforce rights" dispute precise resolved de novo review standard, "giv[e] administrator discretionary authority determine construe Firestone Tire Rubber Bruch, 489 101, 115 (1989). 20 follows individual brings complaining denial entitled (state federal) violated, falls "within of" words, there 21 scope" we examine complaints, (the THCLA), various documents. employer's App. H Pet. Cert. 02-1845, 67a, ¶ 11. primary Vioxx, 12. complained approve payment prescription. Further, JA-25, JA-31, JA-39 JA-40, JA-45 JA-48, JA-108. 22 Similarly, she receives, husband's CIGNA. JA-184, 17. CIGNA, upon admittance major authorized stay day. 18. nurse, more single day despite advice recommendation physician. JA-185, ¶¶ 20, 21. contests decision refuse 20. And, case, connection portions JA-219 JA-221. 23 clear, then, complain about denials Upon paid themselves sought preliminary injunction, Pryzbowski Healthcare, 245 F.3d 266, 274 (CA3 2001) (giving examples issued injunctions).2 24 contend, complained-of violate duties specifically THCLA, "controlled, influenced, participated made affected quality diagnosis, provided" "the 88.001 88.002." 69a, 18; JA-187, 28. contend duty. They analogize interpreting 301, 185, focus Caterpillar Williams, 482 386 (1987) (suit employment constituted collective-bargaining 301). goes, 25 context impose entities "exercise liable damages proximately caused abide 88.002(a). entity's Rather, cause.3 clearly states "[t]he standards Subsections obligation carrier, organization, insured enrollee entity." 88.002(d). administering. 26 interpretation forms claim, exist Petitioners' potential derives obligations So, unlike Caterpillar, federally regulated itself. Cf. Allis-Chalmers Lueck, 471 202, 217 (1985) (state-law bad-faith "duties derive[d] contract"); Steelworkers Rawson, 495 362, 371 (1990) negligence inspection mine pre-empted, inspect arose solely agreement). 27 plans, attempt 66, court.4 came reasons, damages," them." F.3d, 309. But, "elevate form substance evade" "by contract." Allis-Chalmers, 211. mere Ingersoll-Rand, plaintiffs labeled either tort-like. 43 for, inter alia, "`Tortious Breach Contract'"); 61-62 requesting "mental anguish [the] 136 theories). three (compensatory punitive damages); 61 (mental anguish); (punitive damages, mental anguish). plaintiffs' inherent "careful balancing" ensuring encouragement creation 55. [respondents'] immaterial" "they invoke care.'" But already discussed, certainly "ordinary 30 Ultimately, rested line Prudential. There, described our "[W]hile duplicated elements converted equitable 1132(a)(3) (available exclusively courts) money tribunal)." 379. sentence describe why 502(a): attempted convert remedy. Nowhere situation duplicates 31 conclude strictly duplicative Frequently, order receive exemplary plaintiff prove facts bare minimum necessary establish entitlement award. (bad-faith honor needed proved damages). anguish, presumably anguish; element 136; 61. save pre-emption. supplement permitted, claim. C 32 argue—for first time Court—that regulates insurance, saves (and thereby pre-emption).5 unavailing. demonstrate "overpowering policy" determines designed Prudential, 375. example. 33 stated "our [§ 514(b)(2)(A)] concerning provided 1132(a)." ERISA." 54. held, 34 common-sense saving clause, McCarran-Ferguson factors defining business and, most importantly, expression [the plaintiff's] asserting improper processing 514(b)(2)(A)." 57 (emphasis added). 35 Life's reasoning applies full force. obstacle objectives Congress." interpreted light principles conflict pre-emption, arguably characterized "regulating insurance" will vehicle assert addition to, scheme. IV 36 Respondents, amici, relied heavily pre-empt respondents'. "relate [an] plan," 514(a), 1144(a), Brief 35-38; Cicio Does, 321 83, 100-104 (CA2 2003), cert. pending sub nom. Vytra Cicio, 03-69 [REPORTER'S NOTE: 933]; Land 339 1286, 1292-1294 (CA11 2003). 37 cannot read broadly. Pegram, physician-owned-and-operated (which employer pursuant plan) physician, malpractice 215-216. person charged administering benefits; who decided treatments covered. 228. reasoned physician's "eligibility inextricably mixed." 229. "Congress HMO] physicians." 231. 38 though, generally act. 111-113. "At characteristically attach managing assets distributing property beneficiaries." 231; cf. 2A Scott Fratcher, Law Trusts 182, 183 (4th ed. 1987); G. Bogert Bogert, Trustees 541 (rev.2d 1993). Varity Howe, 516 489, 512 (1996) (relevant fiduciaries owe "fiduciary respect documents claims"). 39 principle. highlighting contrasted operation "[t]raditional trustees administer[ing] trust" "physicians whom HMOs act." traditional trust administered "paying buy whereas consume well." "[p]rivate judgments." 232. trustee undoubtedly administrative require judgment. employers somewhat analogous position trust.6 40 defines responsibility [an benefit] 3(21)(A)(iii), 1002(21)(A)(iii). regarding regard, fiduciaries. Corp., 511 (plan "engages act claimant documents"). Also, 503, specifies procedure, requires "afford reasonable opportunity whose been named denying claim." 1133(2). strongly suggests ultimate decisionmaker award participant's beneficiary's denials. CFR 2560.503-1 These regulations, face, apply equally draw distinctions nonmedical determinations. Indeed, imply determinations involving are, just much determinations, e. g., 2560.503-1(h)(3)(iii). Classifying administrators extensively judgments, ordinarily fiduciaries, challenged truly 229, i. e., necessity qua administrator. Put another way, "only make[s] underlying plausibly constitutes maltreatment party deemed employer." 109 (Calabresi, dissenting part). implicated. V 42 judgment reversed, remanded further proceedings opinion.7 ordered. Notes: Together 03-83,CIGNA HealthCare dba al., same &#x2020; Briefs curae reversal AAHP-HIAA Seth P. Waxman, DuMont, Kenneth Bamberger, Stephanie Kanwit; Association Organizations Anthony Shelley Barnett; Chamber Commerce Glen Nager, Traci Lovitt, Stephen Bokat, Robin Conrad. affirmance AARP Sarah Lenz Lock, Michael Schuster, Judith Lichtman; American College Legal Medicine Miles Zaremski; Medical Gary Howell, Thomas Campbell, Jon Ekdahl, Leonard Nelson, Donald Wilcox; Trial Lawyers America Daniel Soloway, Jeffrey White, Casey, Jr.; California Consumer Council Eugene Rhonda Orin, Healy, Trueman; Community Rights Counsel Timothy Dowling; Governments Ruda Crowley; Families USA Lewis; Administration Responsibility Project Sharon Arkin Harvey Frey; National Alliance Model Drug Laws Gerald McHugh, Gregory Heller; Policyholders Arnold Levinson; Senator Kennedy Mr. Zaremski. Court, argue 502(a)(2). point, resolve reference address membership HMOs, delineated 28-30. identify possible opposition petitions certiorari, deem waived. Rule 15.2 take example, exclude cost appendectomy, appendectomy properly attributed itself, applied 514(a); 514(a). alternative exclusive. SeeIngersoll-Rand 142 (holding "[e]ven express [under 514(a)]" "would preempted conflict[ed] directly action"). 514(b)(2)(A), 1144(b)(2)(A), reads, relevant: "[N]othing subchapter shall construed exempt relieve banking, securities." BothPilot support understanding. disability insurers (1987); (1987). often involves judgments. (plaintiff disabled examination undertaken physicians). Yet, held Black Decker Disability Plan Nord, 538 822 (2003) (discussing "treating physician" rule plans). asamicus, positions "make-whole" relief 502(a)(3). Amicus Curiae 27, n. 13. motions remand, expressly so; JA-147 JA-148; JA-298; pp. 34a-35a; 03-83, 40a. chosen pursue including provision, before us, BREYER joins, concurring. today holds totally (ERISA Act), 1132(a). governing preemptive I join opinion. greater enthusiasm, indicated my Great-West Annuity Knudson, 534 204 rising judicial chorus [this] revisit unjust increasingly tangled regime." DiFelice 346 442, 453 2003) (Becker, concurring). coupled encompassing cramped construction "equitable relief" allowable 502(a)(3), "regulatory vacuum" exists: "[V]irtually very few substitutes provided." 456, 457 series yielded host persons adversely ERISA-proscribed wrongdoing gain make-whole relief. 134 stated, dicta: "[T]here stark absence—in [ERISA] history—of intention extracontractual consequential 148. Then, Mertens Hewitt Associates, 508 248 (1993), 502(a)(3)'s term "`equitable relief' refer[s] categories typically equity (such mandamus, restitution, compensatory damages)." 256 original). Most recently, Great-West, ruled "§ relief," excludes imposition personal contractual money." 221 array lower opinions documents, see, DiFelice; 83 933], fresh consideration availability 502(a)(3) plainly order. 106, 107 part) ("gaping wound" breadth preemption healed until "start[s] over" "wipe[s] slate clean"); DiFelice, 467 ("The vital thing quickly, current untenable."); Langbein, What Means "Equitable": Trail Error Mertens, 103 Colum. Rev. 1317, 1365 (hereinafter Langbein) needs realign tradition [when for] `appropriate relief.'"). Government notes amelioration. Recognizing "this Section non-fiduciary," currently written interpreted, "allo[w] least `make-whole' breaching general divided bench." 27-28, (emphases added); ante, 220 ("entity determinations" "plan fiduciary"); Tr. Oral Arg. ("Aetna [a fiduciary]—and processing."). points out, 502(a); therefore, 221, 7. Government's suggestion indicate effective similarly circumstanced might fruitfully pursue. replicate core standard relief." Langbein 1319. anticipate Congress, confirm.

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