Health Administration Responsibility Project
Relevant Case Citations
This is an alphabetical list of cases referred to elsewhere
on this site.
CT: stands for Court. First 2 letters are US or state,
next 2 for court, as CA=Court of appeals, SC=Supreme Court, etc.
DT: stands for date, as yyyymmdd
ABS: stands for a brief abstract
Please send suggestions for new citations to the
Ace v. Aetna Life Ins. Co.(Revised)
- 139 F.3d 1241
- CT:USCA9, DT:19980507
- ABS: State bad-faith disability insurance claims with
discussion of standards for handling claims denials and
for punitive damages, under Alaska law.
Aetna v. Davila
- No. 02-1845
- CT:USSC, DT:20040621
- ABS: ERISA preempts all state remedies directed against HMOs which insure ERISA plans.
Aetna v. Texas
- No. 98-20940
- CT:USCA5, DT:20000620
- ABS: Preempting most of the Texas HMO law, SB386
Allis-Chalmers Corp. v. Lueck
- 471 U.S. 202
- CT:USSC, DT:19850416
- ABS:State bad-faith disability insurance claims dependent
upon analysis of the terms of a collective-bargaining agreement,
are pre-empted by the federal Labor Management Relations Act.
Pre-emption is also necessary to preserve the central role of
arbitration in the resolution of labor disputes.
Allstate Ins. v. 65 Security Plan
- 879 F.2d 90
- CT:USCA3, DT:19890719
- ABS: An insurance company's state-law reimbursement claim against
an ERISA plan is not removable to US court.
Andrews-Clarke v. Travelers
- 984 F. Supp. 49
- CT:USDCMA, DT:19971030
- ABS:A scathing indictment of ERISA preemption and managed
care by a Federal district judge, even as he denies all relief to
the family of a man killed by HMO negligence, or worse.
Aranda v. Community Psychiatric Centers
- 945 F. Supp. 1485
- CT:USDCWDOK, DT:19961001
- ABS: A federal False Claims suit for a psychiatric hospital's
failure to provide a safe environment for Medicaid patients
survives 12(b)(6) motion.
Barnett Bank v. Nelson
- 517 US 25
- CT:USSC, DT:19960326
- ABS: A federal law allowing some banks to sell insurance preempts
a state law forbidding it.
The McCarran-Ferguson Act's anti-pre-emption rule does not govern
this case, because the Federal Statute
"specifically relates to the business of insurance."
Bast v. Prudential
- 150 F.3d 1003
- CT:USCA9, DT:19980602
- ABS:Suit for wrongful death due to denial of coverage for ABMT.
ERISA preempts all state claims, and provides no relief.
Constructive trust expressly denied as equitable relief.
Bendixen v. Standard Insurance
- 185 F.3d 939,
- 99 C.D.O.S 6138
- CT:USCA9, DT:19990707
- ABS: ERISA administrator's conflict of interest will not
affect deferential standard of review, unless it is "serious".
Bergt v. Ret. Plan for Pilots Empl. by Mark Air
- 293 F.3d 1139
- CT:USCA9, DT:20020619
- ABS:Unambiguous terms of an ERISA plan master document, more favorable to employees,
control over contrary unambiguous provisions in the SPD. Contra proferentum applies.
Berlin v. Bush Lincoln
- 179 Ill. 2d 1
- CT:ILCA4 , DT:19960412
- ABS: Hospital could not enforce restrictive covenant against
doctor ex-employee, because of law against corporate
practice of medicine.
Bernstein v. Capitalcare
- 70 F.3d 783
- CT:USCA4, DT:19951204
- ABS: ERISA plan administrator denied benefits upon inadequate data
Discussion of Standard of Review and Conflict of Interest.
Beynon v. Garden Grove
- 100 Cal. App. 3d 698
- CT:CACA4., DT:19800104
- ABS: A clause in a contract, unknown to P, which allowed D to
unilaterally choose to re-arbitrate, was adhesionary and
against public policy.
Black & Decker v. Nord
- No. 02—469
- CT:USSC DT:20030527
- ABS: ERISA plans need not follow "treating physician" rule
Booton v. Lockheed
- 110 F.3d 1461
- No. 95-56381
- CT:USCA9, DT:19970411
- ABS: Benefit denials by an ERISA plan administrator are
entitled to deference only if the plan complies with
the notice requirements of 29 C.F.R. @ 2560.503-1(f).
Boyd v. Albert Einstein MC
- 547 A.2d 1229
- CT:PASC, DT:19880922
- ABS: HMO Negligent qualification & oversight of MDs.
Though a physician is an independent contractor with
respect to the hospital, he may nevertheless be an
agent of the hospital with respect to the patient.
ERISA doesn't preempt malpractice claims.
Broughton v. Cigna
- 21 Cal.4th 1066
- CT:CASC, DT:19991202
- ABS: An arbitration clause in a health insurance policy
does not compel arbitration of the injunctive relief portion of a claim for violation of the California Consumers Legal Remedies Act, CC 1750, but an action for damages under the CLRA is fully arbitrable and should be severed from an injunctive relief action.
Brown v. BC/BS of AL
- 898 F.2d 1556
- CT:USCA11, DT:19909425
- ABS:Analysis of ERISA Standards of Review, in
light of Firestone.
Bynum v. Cigna
- CT:USCA4, DT:20020419
- ABS:The court reversed the decision of an ERISA insurer/administrator
to refuse payment for treatment of congenital torticollis, as "cosmetic".
Cannon v. Group Health Svc of OK
- 77 F.3d 1270
- CT:USCA10, DT:19960228
- ABS: A wrongful death suit for denial of care, thrown out
of court because of ERISA preemption.
Carparts v. Automotive Wholesaler's
- 37 F.3d 12
- CT:USCA1, DT:19941012
- ABS: A self-insured multi-employer benefit plan is an "employer"
for purposes of ADA Title I. It may be a "place of public
accomodation" for purposes of ADA Title III.
Cisneros v. Unum
- 134 F.3d 939
- CT:USCA9, DT:19980120
- ABS: California's "notice-prejudice" rule is not preempted
by ERISA, as it is a regulation of insurance.
Coburn v. Kaiser
- 19 Cal.App. 4th 513
- CT:CACA2, DT:19930915
- ABS: Neutral Arbitrator had been a party arbitrator for HMO
and failed to disclose it.
New arbitration was ordered.
Corcoran v. United
- 965 F.2d 1321
- CT:USCA 5, DT:19920626
- ABS: The classic case holding that ERISA both pre-empted the
plaintiffs' medical malpractice claim and precluded them from
recovering emotional distress damages. Says P can't collect
under either state or US laws.
Crull v. Gem
- 58 F.3d 1386
- CT:USCA 9, DT:19950614
- ABS: Claims preempted by ERISA should be considered for relief
under ERISA's civil enforcement scheme, 502(a).
Davis v. Continental
- 59 Cal.App 4th 205
- CT:CACA2, DT:19971117
- ABS: Waiver of arbitration may be found where the party seeking it
has (1) previously taken steps inconsistent with an intent to
invoke it, (2) unreasonably delayed in seeking it, or (3) acted in
bad faith or with willful misconduct, as by engaging in extensive
Delta Dental v. Mendoza
- 139 F.3d 1289
- CT:USCA 9, DT:19980327
- ABS: Federal court must abstain when state insurance regulations
are being enforced in state court against insurer which
contracts with an ERISA plan.
Desario v. Thomas
- 139 F.3d 80
- CT:USCA2, DT:19980224
- ABS: MedicAid may limit services and equipment it provides
to those not useful to healthy persons.
Dillingham v. Cal. Div. of Labor Stds.
- 519 US 316
- CT:USSC, DT:19970218
- ABS: Greatly limits extent of ERISA preemption of state law,
here, minimum wage laws in apprenticeship programs. Scalia
concurrence suggests the "relates to" test is dead, and
conventional field/conflict preemption analysis should
Dishman v. UNUM
- 269 F.3d 974
- CT:USCA9, DT:20010508
- ABS: State claims for Invasion of Privacy in connection with
investigation of disability insured are NOT preempted by ERISA.
Drolet v. Healthsource
- 968 F. Supp. 757
- CT:USDCNH, DT:19970326
- ABS: An ERISA beneficiary may sue for breach of fiduciary
duty. Claims determinations are fiduciary acts.
Dukes v. U.S.Healthcare
- 57 F3d 350
- CT:USCA3, DT:19950616
- ABS: ERISA 502(a) does not preempt claims for Medical Malpractice
against HMO's, and such cases are not removable.
State courts may decide whether they are preempted by 514(a).
Dunn v. Praiss
- 256 N.J. Super. 180; 606 A.2d 862
- CT:NJCA, DT:19920504
- ABS: Affirms vicarious liability of HMO for Dr's malpractice.
Where the physician is a direct employee,
respondeat superior may be applied.
Elam v. College Park Hosp.
- 132 Cal. App. 3d 332
- CT:CACA4, DT:19820527
- ABS: Hospital is liable for malpractice by
Agents, Ostensible Agents, and
Independent members of the Staff.
Even if MD was selected by patient.
National Elevator v. Calhoon
- 957 F.2d 1555
- CT:USCA10, DT:19920226
- ABS: ERISA preempts state ruling that discriminates against workers
in ERISA training programs.
Elsesser v. Phil. Osteopathic
- 802 F. Supp. 1286
- CT:USDCEDPA, DT:19920930
- ABS: Vicarious liability claims against HMO were not
preempted by ERISA.
- 15 Cal.4th 951
- CT:CASC, DT:19970630
- ABS: Kaiser's behavior in delaying and rigging
mandatory arbitration justified setting it aside.
Erickson v. Aetna
- 71 Cal.App.4 646
- CT:CACA4, DT:19990421
- ABS: The federal Arbitration Act preempts conflicting state
laws which burden arbitration more than other contractual
clauses. Ambiguities must be construed in favor of arbitration
rather than against the drafter.
Express Scripts v. Wenzel,
- (No. 00-2788, 8/23/2001)
- CT:USCA8, DT:20010823
- HMOs are Insurance Companies for purposes of the ERISA Saving clause,
so state HMO regulations are not preempted by ERISA.
Farquhar v. Blue Cross
- 67 Cal.App.4th 42
- CT:CACA2, DT:19981006
- ABS: An adhesive mandatory arbitration clause may allow
classwide arbitration, which will not be preempted by the
Federal Arbitration Act.
Firestone v. Bruch
- 489 U.S. 101
- CT:USSC, DT:19890221
- ABS: De novo review is the appropriate standard for reviewing
denial of benefits, unless the plan gives
the administrator discretionary authority,
when a deferential standard is appropriate.
The arbitrary and capricious standard should not be
imported into ERISA on a wholesale basis.
If a plan gives discretion to a fiduciary, however, the conflict
of interest must be weighed as a factor in determining
whether there is an abuse of discretion.
ERISA explicitly authorizes suits against fiduciaries
and plan administrators to remedy statutory violations,
including breaches of fiduciary duty and lack of compliance
Humana v. Forsyth
- 114 F.3d 1467
- CT:USSC, DT:19990120
- ABS: Humana charged enrollees a copayment of 20% of hospital bills, but
secretly got a discount. A unanimous court held that enrollees could
sue under civil RICO, which was not preempted by McCarran-Ferguson.
General American v. Castonguay
- 984 F.2d 1518
- CT:USCA9, DT:19930201
- ABS: ERISA plan trustees can't be held personally liable
for the trust's contracts with outside insurers, for
A law is preempted if it regulates any of the relationships
regulated by ERISA, regardless of whether it also
regulates other non-ERISA relationships.
Gewecke v. St. Joseph's
- 130 F.3d 1355
- CT:USCA9, DT:19971210
- ABS: Claims by an EBP against its own 3d party administrator
and re-insurer are not preempted by ERISA.
Giles v. NYLCare
- 172 F.3d 332
- No. 97-20840
- CT:USCA5, DT:19990409
- ABS: Discussion of jurisdiction, removal and remand under ERISA,
Washington Physicians Service v. Gregoire
- 147 F.3d 1039
- CT:USCA9, DT:19980824
- ABS: A state law requiring all HMOs to cover "alternative"
treatments" is not preempted by ERISA, if it does not
apply to self-insured plans.
Grijalva v. Shalala
- 152 F. 3d 1115
- CT:USCA9, DT:19980812
- ABS: HMO denials of medical services to Medicare
beneficiaries constitute state action and regulations
must be written so as to provide due process.
- The Settlement Agreement of 8/9/2000.
Gross v. Recabaren
- 206 Cal.App. 3d 771
- CT:CACA2, DT:19881216
- ABS: Once signed, a mandatory arbitration clause is in effect
between the parties till revoked in writing.
Herdrich v. Pegram
- 154 F.3d 362
- CT:USCA7, DT:19980818
- ABS: Doctors who make benefit decisions are ERISA fiduciaries.
If they also set their own salaries they may be in breach
of their fiduciary duties.
- Pegram v. Hedrich or Syllabus.
- 530 US 211
- CT:USSC, DT:20000612
Hewlett-Packard v. Barnes
- 571 F.2d 502
- CT:USCA9, DT:19780314
- ABS: ERISA preempts the California Knox-Keene act with respect to
Hughes v. Blue Cross
- 215 Cal.App. 3d 832
- CT:CACA1, DT:19891114
- ABS: Unreasonable denial of coverage by an insurance company
warrants damages for breach of implied warranty of good faith
and fair dealing.
Defense of ERISA preemption of 502(a)(1)(b) claims
is waived if not raised at trial.
Ingersoll-Rand v. McClendon
- 498 US 133
- DOCKET 89-1298
- CT:USSC, DT:19901203
- ABS: A state law providing a cause of action for firing
a worker to avoid paying a pension, is preempted by
ERISA, but there may be a federal action under ERISA 510.
IT Corp. v. General American
- 107 F.3d 1415
- No. 94-55947
- CT:USCA9, DT:19970303
- ABS: A health benefits plan administrator can be sued
as a fiduciary under ERISA.
Jones v. Kodak
- 169 F.3d 1287
- No. 97-4142
- CT:USCA10, DT:19990304
- ABS: Terms of an ERISA plan are not subject to judicial
review. They may be below the community standard of care.
They need not be disclosed to participants.
If Administrator is an employee of the company running a
self-funded plan, that is not a per se conflict of interest,
and he is entitled to a deferential standard of review.
Kanne v. Connecticut General
- 867 F.2d 489
- CT:USCA9, DT:19861004
- ABS: Voluntary Employee-paid insurance will be
subject to ERISA if the employer does no more than
Private state causes of action are preempted by ERISA
even if within otherwise saved insurance regulation.
Kearney v. U.S.Healthcare
- 859 F. Supp. 182
- CT:USDCEDPA, DT:19940803
- ABS: Claims against an ERISA HMO for
misrepresentation, denial of benefit,
negligence and breach of contract will be dismissed.
Vicarious liability claims for negligent treatment
are NOT preempted.
Kearney v. Standard Insurance
- 175 F.3d 1084
- No. 96-16539
- CT:USCA9, DT:19980421
- ABS: An ERISA administrator with a conflict of interest is to
afforded very little deference. The court need not limit itself
to evidence before the administrator.
- This case was reheard by the 9th Circuit en banc, and 11
judges produced 6 opinions, confusing the issue even further.
Here are those opinions.
Kekis v. Blue Cross
- 815 F. Supp. 571
- CT:USDCNDNY, DT:19930312
- ABS: Court ordered ERISA HMO to cover HDC-ABMT for breast cancer
where policy defined "experimental" as "Having no medical value".
Kuhl v. Lincoln National
- 999 F.2d 298
- CT:USCA8, DT:19930607
- ABS: An HMO refused to allow treatment advised by
every doctor involved. By the time it relented, the
member had deteriorated, and died. ERISA preempted
all his claims and allowed no damages.
Lang v. Long-Term Disability Plan
- 125 F.3d 794
- No. 96-56080
- CT:USCA9, DT:19970911
- ABS: Under Firestone, a plan administrator's decision is
entitled to the deference specified in the contract, unless
the member can show a material probability that it was
affected by conflict of interest, and administrator can't
adequately rebut. Then a de novo standard is used instead
of 'arbitrary & capricious'
Lapine v. Kyocera
- 130 F.3d 884
- No. 96-15319
- CT:USCA9, DT:19971209
- ABS: An arbitration agreement may allow for heightened
judicial review, beyond the statutory grounds allowed
in the FAA.
Lee v. Blue Cross
- 10 F.3d 1547
- CT:USCA11, DT:19940106
- ABS: An ERISA plan administrator denied benefits.
Excellent outline of Standard of Review and
Conflict of Interest.
Maciejewski v. Alpha Systems
- 73 Cal.App.4th 1372
- CT:CACA4, DT:19990805
- ABS: A non-HMO case outlining unconscionability
as a means to defeat mandatory arbitration.
Mackey v. Lanier
- 486 U.S. 825
- CT:USSC, DT:19880617
- ABS: State-law garnishment of ERISA plan benefits
are NOT preempted.
State laws trying to help ERISA are preempted.
Mattive v. Healthsource
- 893 F.Supp. 1559
- CT:USDCSDGA, DT:19950711
- ABS: Preliminary injunction granted to force payment for
HDC/PSCR, in spite of policy exclusions for ABMT and
Maune v. Int. Bro. Elect. Workers
- 83 F.3d 959
- No. 95-2612
- CT:USCA8, DT:19960513
- ABS: If patient loses ERISA case against HMO, lawyers fees
shouldn't be awarded if suit was brought in good faith.
McCall v. Pacificare
- 74 Cal.App.4th 257
- CT:CACA4, DT:19990817
- ABS: While claims for Medicare benefits are subject to remedy
exhaustion and federal jurisdiction, state claims for damages
resulting from denied benefits are Not.
Cal. HSC 1371.25 only prevents HMOs from demanding indemnity
from providers. It does Not shield HMOs from vicarious liability
for actions of providers.
- UPHELD by Calif. Supreme Court, 25 Cal.4th 412, 5/3/2001
McGann v. H & H Music
- 946 F.2d 401
- CT:USCA5, DT:19911104
- ABS: Employer may amend plan to eliminate coverage of
disease patient has submitted claims for.
McHugh v. USAA
- 98 C.D.O.S. 7465, No. 97-35019
- CT:USCA9, DT:19990106
- ABS: As a principle of federal common law, courts will protect
the reasonable expectations of insureds even though the policy
indicates that such expectations are contrary to the expressed
intention of the insurer.
Mertens v. Hewitt
- 508 U.S. 248
- CT:USSC, DT:19930601
- ABS: In ERISA, Congress intended "equitable relief" to include
only those types of relief that were typically available in equity,
such as injunction, mandamus, and restitution,
but no monetary damages.
Metropolitan Life v. Taylor
- 481 U.S. 58
- CT:USSC, DT:19870406
- ABS: Claims under ERISA 502(a)(1)(B) are removable to federal court,
under the doctrine of "Complete Preemption",
overriding the "Well-Pleaded Complaint" rule.
Metropolitan Life Ins. v. Massachusetts
- 471 U.S. 724
- CT:USSC, DT:19850603
- ABS: A law "which regulates insurance" within the meaning of
ERISA @ 514(b)(2)(A) is not pre-empted by @ 514(a) as
it applies to insurance contracts purchased for
plans subject to ERISA.
However, it cannot apply to benefits furnished
DIRECTLY by the EBP, as the EBP may not be
'deemed' to be an insurance company, per 514(b)(2)(B).
A law which requires bargained for insurance contracts
to have certain benefits is not preempted by NLRA.
Moradi-Shalal v. Fireman's Fund
- 46 Cal. 3d 287
- CT:CASC, DT:19880818
- ABS: An insurer has no liability to a 3d party claimant
for unfair insurance practices.
Moran v. Rush Prudential
- 230 F.3d 959
- No. 99-2574
- CT:USCA7, DT:20001019
- ABS: A state law requiring 3d party review of medical necessity
decisions is not preempted by ERISA for an insured EBP.
- UPHELD by the US Supreme Court
- Rush Prudential HMO, Inc. v Debra C. Moran et al.
- 536 US 355
- CT:USSC, DT:20020620
Moreno v. Health Partners
- 4 F. Supp. 2d 888
- CT:USDCAZ, DT:19980414
- ABS: A medical malpractice claim against an HMO doctor is
not preempted by ERISA. Good review of 9th Cir. preemption
analysis since Travelers.
Murphy v. Medical Examiners of Arizona
- 949 P.2d 530
- CT:AZCA1, DT:19970715
- ABS: Insurance reviewers are subject to discipline by
State Medical Boards.
Murphy v. IBM
- 23 F.3d 719
- CT:USCA2, DT:19940505
- ABS: Where an ERISA-covered benefit plan gives the plan
administrator discretionary authority to determine
eligibility for benefits, the administrator's decision
will not be disturbed unless it is
arbitrary and capricious.
But see Firestone.
Napoletano v. Cigna
- 680 A.2d 127
- CT:CTSC, DT:19960723
- ABS: An HMO fired doctors. They and their patients sued
for misrepresentation, unfair trade and insurance practices,
breach of contract, breach of an implied covenant of good
faith and fair dealing, and tortious interference with business
expectancies. These were held to be NOT preempted by ERISA!
It's not clear why Cigna didn't remove to federal court.
Northern Group Svcs v. Auto Owners Ins.
- 833 F.2d 85
- CT:USCA6, DT:19871113
- ABS: Even a Self-insured ERISA plan may be subject to state
insurance regulation, if the state's regulatory interest
outweighs the federal interest in uniformity. Concerns
allocation of risks among insurers.
Nightingale Nursing v. Blue Cross
- 41 F.3d 1476
- CT:USCA11, DT:19950109
- ABS: Denial of reimbursement under ERISA was arbitrary and capricious,
and conflict of interest existed
Pappas v. Asbel
- 450 Pa. Super. 162
- CT:PASC, DT:19981223
- ABS: Negligent delay in authorizing covered care is not
preempted by ERISA.
- FLASH! 6/19/2000 - Vacated by US Sup. Ct. and remanded
for review in light of Pegram.
- FLASH!! 4/3/2001 - Reaffirmed by PA Sup. Ct. on remand!
- 768 A.2d 1089 (Pa. 2001)
Pacificare of OK v. Burrage
- 59 F.3d 151
- CT:USCA10, DT:19950711
- ABS: ERISA does not preempt a medical malpractice claim.
As long as a state law does not affect the structure,
administration, or type of benefits provided by an ERISA plan, the
mere fact that it has some economic impact on the plan does not
require that it be invalidated.
Pfizer v. Aetna
- 59 Cal.App.4th 840
- CT:CACA4, DT:19971029
- ABS: An insured may discover insurer's handling of similar
cases, in a CGL policy, to disclose ambiguity.
Phoenix Mutual v. Adams
- 30 F.3d 554
- CT:USCA4, DT:19940727
- ABS: ERISA preempts state "substantial compliance" laws
concerning changes of insurance beneficiaries. The savings
clause doesn't apply.
Pilot Life v. Dedeaux
- 481 U.S. 41
- CT:USSC, DT:19870406
- ABS: ERISA preempts suits for denial of benefits
even against an independent insurance company
paid by the EBP.
Only laws Explicitly regulating insurance are
saved from preemption, not laws of general applicability.
"State common law causes of action arising from
the improper processing of a claim
are preempted by federal law."
Wrongful death is a general tort and
clearly was not specifically tailored by the state to regulate
Pohl v. National Benefits
- 956 F.2d 126
- CT:USCA7, DT:19920131
- ABS: ERISA administrator is not a fiduciary in the exercise
of its ministerial functions.
Pryzbowski v. U.S.Healthcare
- 245 F.3d 266
- CT: USCA3, DT:20010327
- ABS: Negligent delay in authorizing covered care IS
preempted by ERISA.
Reddick v. Chater
- 157 F.3d 715
- CT:USCA9, DT:19981006
- ABS: Patient with CFS applied for SS disability.
Unless there is affirmative evidence showing that the
claimant is malingering, the ALJ's reasons for rejecting
her testimony must be "clear and convincing."
Reilly v. Blue Cross
- 846 F.2d 416
- CT:USCA7, DT:19880505
- ABS: An old, pre-Firestone case, discussing the arbitrary
and capricious standard of review of denials under ERISA.
Rice v. Panchal
- 65 F.3d 637
- CT:USCA7, DT:19950912
- ABS: Complete preemption is required where a state law claim
cannot be resolved without an interpretation of the contract
governed by federal law.
Vicarious liability for malpractice is not preempted
Mass. Mutual v. Russell
- 473 U.S. 134
- CT:USSC, DT:19850627
- ABS: ERISA allows no remedy for damages caused by unreasonable
delay by a plan in paying covered benefits.
Saika v. Gold
- 49 Cal.App.4th 1074
- CT:CACA4, DT:19960730
- ABS: An arbitration agreement which allows either side to call
for a trial de novo if the award is over $25,000, is illusory,
and one-sided for the provider. The trial de novo clause will
not be enforced.
Sedima v. Imrex
- 473 U.S. 479
- CT:USSC, DT:19850701
- ABS: A private RICO claim does not require that the defendant
have been convicted of the predicate "racketeering acts", nor
that the plaintiff have suffered "racketeering injury".
Shannon v. McNulty
- 718 A.2d 828
- CT:PAsup, DT:19981005
- ABS: Corporate and Vicarious liability of HMO for fetal loss.
Shaw v. Delta Airlines
- 463 U.S. 85
- CT:USSC, DT:19830624
- ABS: State Law is pre-empted with respect to ERISA benefit plans
only insofar as they prohibits practices that are lawful under
Disability portions of ERISA plans are not subject to state law.
Separate disability plans are not subject to ERISA.
Shea v. Esensten I
- 107 F.3d 625
- No. 95-4029MN
- CT:USCA8, DT:19970226
- ABS: It is a breach of fiduciary duty under ERISA for a
health plan to withhold from a patient information about
physician incentives to withhold medical care.
Shea v. Esensten II
- 208 F.3d 712
- No. 99-1388
- CT:USCA8, DT:20000331
- ABS: A state professional negligence suit against a physician
for withholding from a patient information about physician incentives
to withhold medical care, is not preempted by ERISA.
Silkwood v. Kerr-McGee
- 464 U.S. 238
- CT:USSC, DT:19840111
- ABS: Extensive discussion of preemption theory.
Spain v. Aetna
- 11 F.3d 129
- CT:USCA9, DT:19931206
- ABS: State wrongful death suit for denial of
benefits is preempted by ERISA, removed and dismissed.
Relies on Pilot Life v. Dedeaux
Spray et al v. Associated
- 71 Cal.App.4th 1260
- CT:CACA2, DT:19990504
- ABS: Failure of an insurer to give a statutorily required
notice of time limits will estop the insurer from invoking
the time limit as a defense, even if the statute
gave no private cause of action.
St. Charles v. Kender
- 38 Mass. App. Ct. 155; 646 N.E.2d 411
- CT:MACA, DT:19950217
- ABS: HMO member may sue for breach as a 3d party beneficiary of
the contract between HMO and physician, but may receive only
nominal damages in the absence of physical personal injury.
Taggart v. Life & Health Benefits
- 617 F.2d 1208
- CT:USCA5, DT:19800530
- ABS: A group pooling the funds of several small employers
so as to buy group health insurance is not subject to ERISA.
Taylor v. Blue Cross
- CT:MICA, DT:19940620
- ABS: Scientific justification of HDC/ABMT in breast cancer
Corp. Health Ins. Inc. v. Texas Dept. of
Insurance (re Texas SB386)
- 12 F.Supp. 2d 597
- CT:USDCSDTX, DT:19980918
- ABS: State laws banning gag clauses, banning doctor indemnity
clauses, requiring 3d party review of HMO coverage decisions,
or providing alternative remedies for coverage denials
are preempted by ERISA. State law suits relating to
quality of care are not preempted.
NYSCBCBS v. Travelers Ins.
- 514 US 645
- CT:USSC, DT:19950426
- ABS: State surcharges on insurers do not "relate to" employee
benefit plans within the meaning of S514(a) and,
thus, are not pre-empted.
Tremain v. Bell Industries
- 196 F.3d 970
- CT:USCA9, DT:19991116
- ABS:In attempting to defeat deference to an ERISA
administrator's decision, beneficiary may introduce new evidence
of actual conflict of interest.
Turner v. Kaiser
- No. B121570
- CT:CACA2, DT:19981124
- ABS: A party enforcing mandatory arbitration against an indigent
party may have to pay all arbitration fees.
Varity v. Howe
- 116 S. Ct. 1065
- CT:USSC, DT:19960319
- ABS: Reiterates an ERISA beneficiary's right to sue
for Breach of Fiduciary Responsibility, but isn't
a case involving MCOs.
Ward v. UNUM
- No. 97-1868
- CT:USSC, DT:19990420
- ABS: The California "Notice-Prejudice" rule,
which requires a showing of prejudice
to the insurer to deny benefits for late notice, is a law
regulating insurance, and therefore not preempted by ERISA.
Wheeler v. St. Joseph Hosp.
- 63 Cal.App.3d 345
- CT:CACA4, DT:19761104
- ABS: An arbitrator's failure to reveal possible bias is
grounds for vacating the arbitration award.
An order denying a petition to compel
arbitration is expressly made appealable
An order compelling arbitration is nonappealable.
However, a party compelled to arbitrate
may appeal the validity of the order on
his appeal from a judgment confirming an award.
In order to be binding,
an arbitration clause
in a hospital's "Conditions of Admission" form
should be called to the patient's attention and
he should be given an explanation
of its meaning and effect,
including any options available to him.
Wickline v. California
- 192 Cal.App.3d 1630
- CT:CACA 2, DT:19870730
- ABS: UR-forced early discharge led to injury.
"Third party payors of health care services
can be held legally accountable when medically
inappropriate decisions result from defects in
the design or implementation of cost containment
mechanisms as, for example, when appeals made on
a patient's behalf for medical or hospital care
are arbitrarily ignored or unreasonably disregarded
But Plaintiff Lost because:
MD had sole discharge responsibility,
decision was within accepted standard of care, and
MD didn't appeal MediCal's UR decision.
Williams v. Healthamerica
- 41 Ohio App.3d 245; 535 N.E.2d 717
- CT:OHCA 9, DT:19871007
- ABS: HMO refused referral to specialist.
Patient paid & was successfully dx'ed & rx'ed.
Court found statutory duty to administer a complaint
system in good faith.
Found evidence of Bad Faith by HMO.
Wilson v. Blue Cross
- 222 Cal.App.3d 660
- CT:CACA 2, DT:19900727
- ABS: Policy allowed 30 hosp. days for depression.
MD requested it. Gratuitous UR denied it.
Pt. committed suicide after discharge.
"The language in Wickline which suggests that
civil liability for a discharge decision rests
solely within the responsibility of a treating
physician in all contexts is dicta."
So court found BC's refusal to pay, a
"substantial factor" in P's death.
Note also poss. breach of contract.
- 145 F.3d 1118
- CT:USCA9, DT:19980611
- ABS: If an employer does no more than deduct and forward
premiums, and distribute insurance certificates, the insurance
is not subject to ERISA.