The U.S. Supreme Court today says it will hear two cases regarding a patient's right to sue a health plan.
In both cases, patients allege that although their doctors recommended treatment, the HMOs negligently refused to cover it.
In Aetna Health Inc. v. Davila, Juan Davila says his physician prescribed the painkiller Vioxx for his arthritis pain because it has a lower rate of gastrointestinal side effects than others. Davila claims that Aetna insisted he take cheaper drugs first, which caused bleeding ulcers and a near heart attack that almost killed him. He sued Aetna for negligence under a Texas patient protection law.
In Cigna Healthcare of Texas Inc. v. Calad, Ruby Calad claims she was discharged from the hospital one day after a hysterectomy, even though her physician recommended a longer length of stay. Calad says she experienced complications that sent her to the emergency room.
The cases were moved to federal court, where they were consolidated for purposes of oral argument. The U.S. 5th Circuit Court of Appeals in New Orleans ruled that patients can sue HMOs for providing substandard care.
The health plans are appealing. Insurers have argued that the 1974 Employee Retirement Income Security Act, or ERISA, does not allow patients to sue plans for monetary damages for denials of care, even in states that have patient protection laws. Plans say patients can sue in federal court, but only for coverage of a benefit that was denied.
"In both of these cases, the key issue is medical necessity and who regulates it," says George Parker Young, the Fort Worth, Texas, attorney representing Calad and Davila. "Did Congress really intend for that to be a federal issue?"