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 webmaster.

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
94-1837
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
97-35429
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
97-55572
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
99-36106
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. Ostensible Agency.
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
#01-1705
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 discovery.
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 be applied.
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.
Engalla v.Permanente
15 Cal.4th 951
#S048811
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 with plans.
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 negligent misrepresentation.
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.
REVERSED
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 self-funded EBPs.
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 "endorse" it.
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
G021588
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 investigational procedures.
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
#00-1021
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 insurance.
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
#99-5920
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 by ERISA.
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 federal law.
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
1994.MI.382
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
98-15252
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 or overruled."
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.
Life
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.
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