Aetna Health Inc. v. Davila
Encyclopedia
Aetna Health Inc. v. Davila, 542 U.S. 200 (2004) United States Supreme Court case that limited the scope of the Texas Healthcare Liability Act.
The effective result of this decision was that the "Texas Healthcare Liability Act" (THCLA) that held utilization review decisions by Managed Care entities to a legal duty of care
according to the laws of Medical practice
in Texas, could not be enforced in the case of Health Benefit plans provided through private employers, because the Texas statute allowed compensatory or punitive damages
to redress losses or deter future transgressions, which were not available under ERISA § 1132. The ruling still allows Texas
to enforce the THCLA in the case of government-sponsored, church-sponsored, or individual health plan policies, which are saved from preemption by ERISA.
HealthCare of Texas, Inc. v. Calad et al., together with Aetna
Health Inc. v. Davila, the Supreme court ruled that Mr. Davila's and Ms. Calad's (the Respondents) state of Texas Causes of Action
, (both involving utilization review decisions by Managed Care
entities that were alleged to adversely affect patient care, where in both cases Utilization review decisions contradicted the advice of the Respondents' personal physicians), fell within ERISA § 1132(a)(1)(B). The Court therefore ruled these complaints were completely pre-empted by ERISA § 1132 (Implied Preemption
), and removable to Federal Court
, therefore giving federal court jurisdiction
over resolution of the complaint
s and defining ERISA as the law to be followed, superseding the applicable Texas statute (the THCLS). Consequently, the limited (in this case) Equitable Remedies
available under ERISA § 1132 must be the exclusive remedies available to redress damage alleged to be suffered as a result of these utilization review decisions.
The ruling was informed largely by ERISA judicial precedent
(judge-made, or common law
), as established early in ERISA's judicial history, especially Pilot Life v. Dedeaux, 1987. In the latter case, the language of ERISA and other evidence of congressional
intent, including ERISA's legislative history
; the expansive interpretation of ERISA's preemption clause (i.e. ERISA supersedes state laws that "relate to" private employer-sponsored benefit plans, with no specific guidance in the wording of the clause as to how Congress intended "relate to" to be interpreted); coupled with ERISA's enforcement scheme, which includes Equitable Remedies
but not Legal Remedies
, led to the conclusion that state law Causes of action
for legal remedies under Mississippi common law for Bad faith
denial of insurance claims, including compensatory and punitive damages
, were not allowed by ERISA.
As Pilot Life challenged a disability insurance claim denial, the equitable remedies that are provided by ERISA might still have been available to Mr. Dedeaux despite this ruling, as ERISA provides several equitable Injunctive
remedies to challenge denials of benefit claims, such mandating that the wrongfully denied benefit be provided.
The biggest distinguishing factor from Pilot Life in the case of "CIGNA v. Calad" was the fact that it was too late for ERISA's powerful injunctive remedies to benefit the Respondents, who had already suffered damages for which equitable relief could not compensate them for their loss or suffering.
Essentially, this Supreme Court decision placed the Respondents' Complaints
, in the status known as "Failure to state a claim upon which relief could be granted" and had to be Dismissed
on their faces. The facts of the case were never elucidated either by Discovery
or Trial
, but the cases were Dismissed by Motion
, as a matter of law, whereby even examining the facts in the most favorable light in favor of the Respondents, the relief they were seeking could not be granted.
As an example, if the Utilization review nurse had negligently applied the discharge protocol for Hemorrhoidectomy
rather than Total Abdominal Hysterectomy
, and if Calad had died from Complications
resulting from the treatment decision to treat her on an outpatient basis with discharge instructions after only 1 day of hospitilization, the case would still have had to be dismissed; the law does not recognize monetary Damages
for negligent actions in Managed Care "administration" of Employer Medical Benefit Plans but does acknowledge that state malpractice laws do apply to treating physicians deciding or administrating the course of a patient's care. Cigna and Aetna both pointed out in oral arguments what has been referred to in ERISA's judicial history as the "Panoply
" of remedies that Calad and Davila might have evoked under ERISA to prevent the damage suffered, to include appeals of the adverse decisions, judicial Injunction
to compel Utilization Review to approve treatment, and a new Texas law that allowed for independent arbitration over Managed Care Utilization Review decisions based on Medical necessity
.
Under the concepts of Tort
s under Anglo
-American
common law (which do not inform the current interpretations of ERISA), these points might best be described as a defense of contributory negligence
.
Perhaps future decisional law modeled after the instant court ruling might inform future laws to ensure that patients not simply "have" legal rights under ERISA to challenge Managed Care
Utilization review decisions, but to put the burden on the Managed Care entities to make sure patients are aware of them and have the opportunity to invoke them before life, safety, or health-threatening medical treatment choices governed by Utilization review can cause irreparable damage or death for which ERISA provides no Remedy
. Such law might be guided by the wording of the statute, that a patient must be "afforded" the opportunity for full and fair review of benefit claim denial or adverse Utilization review decisions.
As in "Miranda", which involves a similar Fifth Amendment
constitutional question of being deprived of Life, Liberty
, or Property
without Due process
of law, "affording the opportunity" for appeal might be enforced not only by the existence of a such statutory rights but by ensuring that the patients are informed of those rights and are given the reasonable opportunity to invoke them.
The ERISA claims procedure laws detailed by the Secretary of Labor (29 CFR 2560.503-1) require written notice for any "Adverse Determination" such as a Utilization review decision not to extend an approved course of treatment, and must provide a reasonable opportunity for a claimant or a representative (in Calad's case, her treating physician) an opportunity to appeal the decision in a timeframe appropriate to the urgency of the situation—in Calad's case, prior to her discharge. These regulations also require that the claims procedure not "contain any provision, and are not administered in a way, that unduly inhibits or hampers the initiation or processing of claims for benefits; a provision or practice that requires payment of a fee or costs as a condition to making a claim or to appealing an adverse benefit determination would be considered to unduly inhibit the initiation and processing of claims for benefits." For example, requiring a patient to agree to pay for a potentially costly medical treatment up front out of pocket to preserve the right to challenge the adverse determination later in court, with no guarantee that the challenge would be successful, and with a high risk of incurring expensive legal costs as well, would be considered "hampering the initiation or processing of claims for benefits", for obvious reasons.
Unfortunately, the claims procedure laws are not always followed, in part because the only recourse set forth by these laws for failure to provide such an appeal process is the right for the patient to consider the appeals process to be exhausted and bring a Civil action
under ERISA. Such an action might in theory be applied for patients like Calad if the patient had a lawyer prepared to file an emergency ex parte
Motion
for a Temporary restraining order
in US District Court
, perhaps even by phone to a Magistrate
, to compel the Utilization review nurse to approve treatment to protect the patient from imminent danger to life or health that might occur from discharging the patient against medical advice
.
As lower Courts are bound by the Precedent
s of higher Courts, as is the Supreme Court bound in large part to its own precedents, there has been great frustrations by the Courts in lawsuits brought by Plaintiff
s who under state common law would be entitled to monetary relief for damages or death suffered as a result of Utilization review nurses breaching a Duty
of care or the laws of the practice of Medicine
by prescribing the treatment plan for a Diagnosis
, as in Calad's case, as complex as "status post total abdominal hysterectomy with vaginal, bladder, and bowel repair", presumptively, before the surgery is even performed, as 1 day of inpatient care with 8 weeks of outpatient care, on the basis of a discharge protocol to be followed that hinges not on the Clinical
judgment of the physician who performed the surgery but the single question, "were there any Complications
of the procedure?"
This frustration was well stated by Justice Becker of the US Court of Appeals
for the Third Circuit in his concurring opinion in Defelice v. Aetna, et al., a frustration succinctly summarized in his quote from a previous decision in "Andrews-Clarke v. Travelers Ins. Co.," (a Complaint
by a widow for the death of her husband as a consequence of a Managed Care Utilization review decision that cut short her husband's physician's recommended in-hospital treatment plan) as follows:
Also, Supreme Court Justice Ginsburg
, in her concurring opinion in CIGNA v. Calad, in which Justice Breyer
joined, expressed the sentiments held by many that either Congress or the Courts revisit the law as currently enforced by statute and precedent:
Cigna stated in their Brief for Petitioner
a position shared by many advocates of Universal health care
, namely, that by rationing
Health Care Plan monetary expenditures by Managed Care entities such as Aetna and CIGNA (through Utilization review), the monetary expenditure (funded through taxes or private employer compensation/benefit packages and employee payroll deductions) for Health Benefit Plans will also be reduced, providing greater health care access to more Americans: "Employers, of course, do not have unlimited funds to pay for employee health benefits. As health benefit costs inevitably increase, employers will inevitably provide fewer benefits to fewer employees. The necessary result will be more Americans without any health care coverage at all—a guaranteed prescription for lower quality overall care."
The effective result of this decision was that the "Texas Healthcare Liability Act" (THCLA) that held utilization review decisions by Managed Care entities to a legal duty of care
Duty of care
In tort law, a duty of care is a legal obligation imposed on an individual requiring that they adhere to a standard of reasonable care while performing any acts that could foreseeably harm others. It is the first element that must be established to proceed with an action in negligence. The claimant...
according to the laws of Medical practice
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....
in Texas, could not be enforced in the case of Health Benefit plans provided through private employers, because the Texas statute allowed compensatory or punitive damages
Damages
In law, damages is an award, typically of money, to be paid to a person as compensation for loss or injury; grammatically, it is a singular noun, not plural.- Compensatory damages :...
to redress losses or deter future transgressions, which were not available under ERISA § 1132. The ruling still allows Texas
Texas
Texas is the second largest U.S. state by both area and population, and the largest state by area in the contiguous United States.The name, based on the Caddo word "Tejas" meaning "friends" or "allies", was applied by the Spanish to the Caddo themselves and to the region of their settlement in...
to enforce the THCLA in the case of government-sponsored, church-sponsored, or individual health plan policies, which are saved from preemption by ERISA.
Ruling
In CIGNACIGNA
Cigna , headquartered in Bloomfield, Connecticut, is a global health services company, owing to its expanding international footprint and the fact that it provides administrative services only to approximately 80 percent of its clients...
HealthCare of Texas, Inc. v. Calad et al., together with Aetna
Aetna
Aetna, Inc. is an American health insurance company, providing a range of traditional and consumer directed health care insurance products and related services, including medical, pharmaceutical, dental, behavioral health, group life, long-term care, and disability plans, and medical management...
Health Inc. v. Davila, the Supreme court ruled that Mr. Davila's and Ms. Calad's (the Respondents) state of Texas Causes of Action
Cause of action
In the law, a cause of action is a set of facts sufficient to justify a right to sue to obtain money, property, or the enforcement of a right against another party. The term also refers to the legal theory upon which a plaintiff brings suit...
, (both involving utilization review decisions by Managed Care
Managed care
...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on...
entities that were alleged to adversely affect patient care, where in both cases Utilization review decisions contradicted the advice of the Respondents' personal physicians), fell within ERISA § 1132(a)(1)(B). The Court therefore ruled these complaints were completely pre-empted by ERISA § 1132 (Implied Preemption
Federal preemption
Federal preemption refers to the invalidation of US state law when it conflicts with Federal law.-Constitutional basis:According to the Supremacy Clause of the United States Constitution,...
), and removable to Federal Court
United States district court
The United States district courts are the general trial courts of the United States federal court system. Both civil and criminal cases are filed in the district court, which is a court of law, equity, and admiralty. There is a United States bankruptcy court associated with each United States...
, therefore giving federal court jurisdiction
Jurisdiction
Jurisdiction is the practical authority granted to a formally constituted legal body or to a political leader to deal with and make pronouncements on legal matters and, by implication, to administer justice within a defined area of responsibility...
over resolution of the complaint
Complaint
In legal terminology, a complaint is a formal legal document that sets out the facts and legal reasons that the filing party or parties In legal terminology, a complaint is a formal legal document that sets out the facts and legal reasons (see: cause of action) that the filing party or parties In...
s and defining ERISA as the law to be followed, superseding the applicable Texas statute (the THCLS). Consequently, the limited (in this case) Equitable Remedies
Equitable remedy
Equitable remedies are judicial remedies developed and granted by courts of equity, as opposed to courts of common law. Equitable remedies were granted by the Court of Chancery in England, and remain available today in most common law jurisdictions. In many jurisdictions, legal and equitable...
available under ERISA § 1132 must be the exclusive remedies available to redress damage alleged to be suffered as a result of these utilization review decisions.
History
The Supreme Court decision reversed a decision of the U.S. Court of Appeals for the 5th Circuit that ERISA did not preempt the state causes of action and could be Remanded to Texas state court to be tried there under Texas law.The ruling was informed largely by ERISA judicial precedent
Precedent
In common law legal systems, a precedent or authority is a principle or rule established in a legal case that a court or other judicial body may apply when deciding subsequent cases with similar issues or facts...
(judge-made, or common law
Common law
Common law is law developed by judges through decisions of courts and similar tribunals rather than through legislative statutes or executive branch action...
), as established early in ERISA's judicial history, especially Pilot Life v. Dedeaux, 1987. In the latter case, the language of ERISA and other evidence of congressional
United States Congress
The United States Congress is the bicameral legislature of the federal government of the United States, consisting of the Senate and the House of Representatives. The Congress meets in the United States Capitol in Washington, D.C....
intent, including ERISA's legislative history
Legislative history
Legislative history includes any of various materials generated in the course of creating legislation, such as committee reports, analysis by legislative counsel, committee hearings, floor debates, and histories of actions taken...
; the expansive interpretation of ERISA's preemption clause (i.e. ERISA supersedes state laws that "relate to" private employer-sponsored benefit plans, with no specific guidance in the wording of the clause as to how Congress intended "relate to" to be interpreted); coupled with ERISA's enforcement scheme, which includes Equitable Remedies
Equitable remedy
Equitable remedies are judicial remedies developed and granted by courts of equity, as opposed to courts of common law. Equitable remedies were granted by the Court of Chancery in England, and remain available today in most common law jurisdictions. In many jurisdictions, legal and equitable...
but not Legal Remedies
Legal remedy
A legal remedy is the means with which a court of law, usually in the exercise of civil law jurisdiction, enforces a right, imposes a penalty, or makes some other court order to impose its will....
, led to the conclusion that state law Causes of action
Cause of action
In the law, a cause of action is a set of facts sufficient to justify a right to sue to obtain money, property, or the enforcement of a right against another party. The term also refers to the legal theory upon which a plaintiff brings suit...
for legal remedies under Mississippi common law for Bad faith
Bad faith
Bad faith is double mindedness or double heartedness in duplicity, fraud, or deception. It may involve intentional deceit of others, or self deception....
denial of insurance claims, including compensatory and punitive damages
Damages
In law, damages is an award, typically of money, to be paid to a person as compensation for loss or injury; grammatically, it is a singular noun, not plural.- Compensatory damages :...
, were not allowed by ERISA.
As Pilot Life challenged a disability insurance claim denial, the equitable remedies that are provided by ERISA might still have been available to Mr. Dedeaux despite this ruling, as ERISA provides several equitable Injunctive
Injunction
An injunction is an equitable remedy in the form of a court order that requires a party to do or refrain from doing certain acts. A party that fails to comply with an injunction faces criminal or civil penalties and may have to pay damages or accept sanctions...
remedies to challenge denials of benefit claims, such mandating that the wrongfully denied benefit be provided.
The biggest distinguishing factor from Pilot Life in the case of "CIGNA v. Calad" was the fact that it was too late for ERISA's powerful injunctive remedies to benefit the Respondents, who had already suffered damages for which equitable relief could not compensate them for their loss or suffering.
Essentially, this Supreme Court decision placed the Respondents' Complaints
Cause of action
In the law, a cause of action is a set of facts sufficient to justify a right to sue to obtain money, property, or the enforcement of a right against another party. The term also refers to the legal theory upon which a plaintiff brings suit...
, in the status known as "Failure to state a claim upon which relief could be granted" and had to be Dismissed
Dispositive motion
In law, a dispositive motion is a motion seeking a trial court order entirely disposing of one or more claims in favor of the moving party without need for further trial court proceedings. "To dispose" of a claim means to decide the claim in favor of one or another party...
on their faces. The facts of the case were never elucidated either by Discovery
Discovery (law)
In U.S.law, discovery is the pre-trial phase in a lawsuit in which each party, through the law of civil procedure, can obtain evidence from the opposing party by means of discovery devices including requests for answers to interrogatories, requests for production of documents, requests for...
or Trial
Trial (law)
In law, a trial is when parties to a dispute come together to present information in a tribunal, a formal setting with the authority to adjudicate claims or disputes. One form of tribunal is a court...
, but the cases were Dismissed by Motion
Motion (legal)
In law, a motion is a procedural device to bring a limited, contested issue before a court for decision. A motion may be thought of as a request to the judge to make a decision about the case. Motions may be made at any point in administrative, criminal or civil proceedings, although that right is...
, as a matter of law, whereby even examining the facts in the most favorable light in favor of the Respondents, the relief they were seeking could not be granted.
As an example, if the Utilization review nurse had negligently applied the discharge protocol for Hemorrhoidectomy
Stapled hemorrhoidectomy
Severe cases of hemorrhoidal prolapse – 3rd and 4th Degree – will normally require surgery. Traditional hemorrhoidectomy is notorious for the level of post operative pain the patient must endure, coupled with a long recuperation period....
rather than Total Abdominal Hysterectomy
Hysterectomy
A hysterectomy is the surgical removal of the uterus, usually performed by a gynecologist. Hysterectomy may be total or partial...
, and if Calad had died from Complications
Complication (medicine)
Complication, in medicine, is an unfavorable evolution of a disease, a health condition or a medical treatment. The disease can become worse in its severity or show a higher number of signs, symptoms or new pathological changes, become widespread throughout the body or affect other organ systems. A...
resulting from the treatment decision to treat her on an outpatient basis with discharge instructions after only 1 day of hospitilization, the case would still have had to be dismissed; the law does not recognize monetary Damages
Damages
In law, damages is an award, typically of money, to be paid to a person as compensation for loss or injury; grammatically, it is a singular noun, not plural.- Compensatory damages :...
for negligent actions in Managed Care "administration" of Employer Medical Benefit Plans but does acknowledge that state malpractice laws do apply to treating physicians deciding or administrating the course of a patient's care. Cigna and Aetna both pointed out in oral arguments what has been referred to in ERISA's judicial history as the "Panoply
Panoply
A panoply is a complete suit of armour. The word represents the ancient Greek πανοπλια. The word παν means "all", and όπλον, "arms". Thus "panoply" refers to the full armour of a hoplite or heavy-armed soldier, i.e...
" of remedies that Calad and Davila might have evoked under ERISA to prevent the damage suffered, to include appeals of the adverse decisions, judicial Injunction
Injunction
An injunction is an equitable remedy in the form of a court order that requires a party to do or refrain from doing certain acts. A party that fails to comply with an injunction faces criminal or civil penalties and may have to pay damages or accept sanctions...
to compel Utilization Review to approve treatment, and a new Texas law that allowed for independent arbitration over Managed Care Utilization Review decisions based on Medical necessity
Medical necessity
Medical necessity is a United States legal doctrine, related to activities which may be justified as reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care. Other countries may have medical doctrines or legal rules covering broadly similar grounds...
.
Under the concepts of Tort
Tort
A tort, in common law jurisdictions, is a wrong that involves a breach of a civil duty owed to someone else. It is differentiated from a crime, which involves a breach of a duty owed to society in general...
s under Anglo
Anglo
Anglo is a prefix indicating a relation to the Angles, England or the English people, as in the terms Anglo-Saxon, Anglo-American, Anglo-Celtic, Anglo-African and Anglo-Indian. It is often used alone, somewhat loosely, to refer to people of British Isles descent in The Americas, Australia and...
-American
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
common law (which do not inform the current interpretations of ERISA), these points might best be described as a defense of contributory negligence
Contributory negligence
Contributory negligence in common-law jurisdictions is defense to a claim based on negligence, an action in tort. It applies to cases where a plaintiff/claimant has, through his own negligence, contributed to the harm he suffered...
.
Perhaps future decisional law modeled after the instant court ruling might inform future laws to ensure that patients not simply "have" legal rights under ERISA to challenge Managed Care
Managed care
...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on...
Utilization review decisions, but to put the burden on the Managed Care entities to make sure patients are aware of them and have the opportunity to invoke them before life, safety, or health-threatening medical treatment choices governed by Utilization review can cause irreparable damage or death for which ERISA provides no Remedy
Legal remedy
A legal remedy is the means with which a court of law, usually in the exercise of civil law jurisdiction, enforces a right, imposes a penalty, or makes some other court order to impose its will....
. Such law might be guided by the wording of the statute, that a patient must be "afforded" the opportunity for full and fair review of benefit claim denial or adverse Utilization review decisions.
As in "Miranda", which involves a similar Fifth Amendment
Fifth Amendment to the United States Constitution
The Fifth Amendment to the United States Constitution, which is part of the Bill of Rights, protects against abuse of government authority in a legal procedure. Its guarantees stem from English common law which traces back to the Magna Carta in 1215...
constitutional question of being deprived of Life, Liberty
Freedom of contract
Freedom of contract is the freedom of individuals and corporations to form contracts without government restrictions. This is opposed to government restrictions such as minimum wage, competition law, or price fixing...
, or Property
Property
Property is any physical or intangible entity that is owned by a person or jointly by a group of people or a legal entity like a corporation...
without Due process
Due process
Due process is the legal code that the state must venerate all of the legal rights that are owed to a person under the principle. Due process balances the power of the state law of the land and thus protects individual persons from it...
of law, "affording the opportunity" for appeal might be enforced not only by the existence of a such statutory rights but by ensuring that the patients are informed of those rights and are given the reasonable opportunity to invoke them.
The ERISA claims procedure laws detailed by the Secretary of Labor (29 CFR 2560.503-1) require written notice for any "Adverse Determination" such as a Utilization review decision not to extend an approved course of treatment, and must provide a reasonable opportunity for a claimant or a representative (in Calad's case, her treating physician) an opportunity to appeal the decision in a timeframe appropriate to the urgency of the situation—in Calad's case, prior to her discharge. These regulations also require that the claims procedure not "contain any provision, and are not administered in a way, that unduly inhibits or hampers the initiation or processing of claims for benefits; a provision or practice that requires payment of a fee or costs as a condition to making a claim or to appealing an adverse benefit determination would be considered to unduly inhibit the initiation and processing of claims for benefits." For example, requiring a patient to agree to pay for a potentially costly medical treatment up front out of pocket to preserve the right to challenge the adverse determination later in court, with no guarantee that the challenge would be successful, and with a high risk of incurring expensive legal costs as well, would be considered "hampering the initiation or processing of claims for benefits", for obvious reasons.
Unfortunately, the claims procedure laws are not always followed, in part because the only recourse set forth by these laws for failure to provide such an appeal process is the right for the patient to consider the appeals process to be exhausted and bring a Civil action
Lawsuit
A lawsuit or "suit in law" is a civil action brought in a court of law in which a plaintiff, a party who claims to have incurred loss as a result of a defendant's actions, demands a legal or equitable remedy. The defendant is required to respond to the plaintiff's complaint...
under ERISA. Such an action might in theory be applied for patients like Calad if the patient had a lawyer prepared to file an emergency ex parte
Ex parte
Ex parte is a Latin legal term meaning "from one party" .An ex parte decision is one decided by a judge without requiring all of the parties to the controversy to be present. In Australian, Canadian, U.K., Indian and U.S...
Motion
Motion (legal)
In law, a motion is a procedural device to bring a limited, contested issue before a court for decision. A motion may be thought of as a request to the judge to make a decision about the case. Motions may be made at any point in administrative, criminal or civil proceedings, although that right is...
for a Temporary restraining order
Injunction
An injunction is an equitable remedy in the form of a court order that requires a party to do or refrain from doing certain acts. A party that fails to comply with an injunction faces criminal or civil penalties and may have to pay damages or accept sanctions...
in US District Court
United States district court
The United States district courts are the general trial courts of the United States federal court system. Both civil and criminal cases are filed in the district court, which is a court of law, equity, and admiralty. There is a United States bankruptcy court associated with each United States...
, perhaps even by phone to a Magistrate
Magistrate
A magistrate is an officer of the state; in modern usage the term usually refers to a judge or prosecutor. This was not always the case; in ancient Rome, a magistratus was one of the highest government officers and possessed both judicial and executive powers. Today, in common law systems, a...
, to compel the Utilization review nurse to approve treatment to protect the patient from imminent danger to life or health that might occur from discharging the patient against medical advice
Against medical advice
Against Medical Advice, or AMA, sometimes known as DAMA, Discharge Against Medical Advice, is a term used with a patient who checks himself out of a hospital against the advice of his doctor. While it may not be medically wise for the person to leave early, in most cases the wishes of the patient...
.
As lower Courts are bound by the Precedent
Precedent
In common law legal systems, a precedent or authority is a principle or rule established in a legal case that a court or other judicial body may apply when deciding subsequent cases with similar issues or facts...
s of higher Courts, as is the Supreme Court bound in large part to its own precedents, there has been great frustrations by the Courts in lawsuits brought by Plaintiff
Plaintiff
A plaintiff , also known as a claimant or complainant, is the term used in some jurisdictions for the party who initiates a lawsuit before a court...
s who under state common law would be entitled to monetary relief for damages or death suffered as a result of Utilization review nurses breaching a Duty
Duty
Duty is a term that conveys a sense of moral commitment to someone or something. The moral commitment is the sort that results in action and it is not a matter of passive feeling or mere recognition...
of care or the laws of the practice of Medicine
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....
by prescribing the treatment plan for a Diagnosis
Diagnosis
Diagnosis is the identification of the nature and cause of anything. Diagnosis is used in many different disciplines with variations in the use of logics, analytics, and experience to determine the cause and effect relationships...
, as in Calad's case, as complex as "status post total abdominal hysterectomy with vaginal, bladder, and bowel repair", presumptively, before the surgery is even performed, as 1 day of inpatient care with 8 weeks of outpatient care, on the basis of a discharge protocol to be followed that hinges not on the Clinical
Clinical significance
In medicine and psychology, clinical significance refers to either of two related but slightly dissimilar concepts whereby certain findings or differences, even if measurable or statistically confirmed, either may or may not have additional significance, either by being of a magnitude that conveys...
judgment of the physician who performed the surgery but the single question, "were there any Complications
Complication (medicine)
Complication, in medicine, is an unfavorable evolution of a disease, a health condition or a medical treatment. The disease can become worse in its severity or show a higher number of signs, symptoms or new pathological changes, become widespread throughout the body or affect other organ systems. A...
of the procedure?"
This frustration was well stated by Justice Becker of the US Court of Appeals
United States court of appeals
The United States courts of appeals are the intermediate appellate courts of the United States federal court system...
for the Third Circuit in his concurring opinion in Defelice v. Aetna, et al., a frustration succinctly summarized in his quote from a previous decision in "Andrews-Clarke v. Travelers Ins. Co.," (a Complaint
Cause of action
In the law, a cause of action is a set of facts sufficient to justify a right to sue to obtain money, property, or the enforcement of a right against another party. The term also refers to the legal theory upon which a plaintiff brings suit...
by a widow for the death of her husband as a consequence of a Managed Care Utilization review decision that cut short her husband's physician's recommended in-hospital treatment plan) as follows:
"Under traditional notions of justice, the harms alleged—if true—should entitle [plaintiff] to some legal remedy on behalf of herself and her children against Travelers and Greenspring. Consider just one of her claims—breach of contractBreach of contractBreach of contract is a legal cause of action in which a binding agreement or bargained-for exchange is not honored by one or more of the parties to the contract by non-performance or interference with the other party's performance....
. This cause of actionCause of actionIn the law, a cause of action is a set of facts sufficient to justify a right to sue to obtain money, property, or the enforcement of a right against another party. The term also refers to the legal theory upon which a plaintiff brings suit...
—that contractual promises can be enforced in the courts—pre-dates Magna CartaMagna CartaMagna Carta is an English charter, originally issued in the year 1215 and reissued later in the 13th century in modified versions, which included the most direct challenges to the monarch's authority to date. The charter first passed into law in 1225...
. It is the very bedrock of our notion of individual autonomy and property rights. It was among the first precepts of the common law to be recognized in the courts of the Commonwealth and has been zealously guarded by the stateU.S. stateA U.S. state is any one of the 50 federated states of the United States of America that share sovereignty with the federal government. Because of this shared sovereignty, an American is a citizen both of the federal entity and of his or her state of domicile. Four states use the official title of...
judiciary from that day to this. Our entire capitalist structure depends on it.
"Nevertheless, this Court had no choice but to pluck [plaintiff's] case out of the stateU.S. stateA U.S. state is any one of the 50 federated states of the United States of America that share sovereignty with the federal government. Because of this shared sovereignty, an American is a citizen both of the federal entity and of his or her state of domicile. Four states use the official title of...
court in which she
sought redress (and where relief to other litigants is available) and then, at the behest of Travelers and Greenspring, to slam the courthouse doors in her face and leave her without any remedy."
Also, Supreme Court Justice Ginsburg
Ruth Bader Ginsburg
Ruth Joan Bader Ginsburg is an Associate Justice of the Supreme Court of the United States. Ginsburg was appointed by President Bill Clinton and took the oath of office on August 10, 1993. She is the second female justice and the first Jewish female justice.She is generally viewed as belonging to...
, in her concurring opinion in CIGNA v. Calad, in which Justice Breyer
Stephen Breyer
Stephen Gerald Breyer is an Associate Justice of the U.S. Supreme Court. Appointed by President Bill Clinton in 1994, and known for his pragmatic approach to constitutional law, Breyer is generally associated with the more liberal side of the Court....
joined, expressed the sentiments held by many that either Congress or the Courts revisit the law as currently enforced by statute and precedent:
"The Court today holds that the claims respondents asserted under Texas law are totally preempted by §502(a) of the Employee Retirement Income Security Act of 1974 (ERISA or Act), 29 U. S. C. §1132(a). That decision is consistent with our governing case law on ERISA's preemptive scope. I therefore join the Court's opinion. But, with greater enthusiasm, as indicated by my dissenting opinion in Great-West Life & Annuity Ins. Co. v. Knudson, 534 U. S. 204 (2002), I also join "the rising judicial chorus urging that CongressUnited States CongressThe United States Congress is the bicameral legislature of the federal government of the United States, consisting of the Senate and the House of Representatives. The Congress meets in the United States Capitol in Washington, D.C....
and this Court revisit what is an unjust and increasingly tangled ERISA regime." DiFelice v. AETNA U. S. Healthcare, 346 F. 3d 442, 453 (CA3 2003) (Becker, J., concurring)."
Cigna stated in their Brief for Petitioner
Brief (law)
A brief is a written legal document used in various legal adversarial systems that is presented to a court arguing why the party to the case should prevail....
a position shared by many advocates of Universal health care
Universal health care
Universal health care is a term referring to organized health care systems built around the principle of universal coverage for all members of society, combining mechanisms for health financing and service provision.-History:...
, namely, that by rationing
Rationing
Rationing is the controlled distribution of scarce resources, goods, or services. Rationing controls the size of the ration, one's allotted portion of the resources being distributed on a particular day or at a particular time.- In economics :...
Health Care Plan monetary expenditures by Managed Care entities such as Aetna and CIGNA (through Utilization review), the monetary expenditure (funded through taxes or private employer compensation/benefit packages and employee payroll deductions) for Health Benefit Plans will also be reduced, providing greater health care access to more Americans: "Employers, of course, do not have unlimited funds to pay for employee health benefits. As health benefit costs inevitably increase, employers will inevitably provide fewer benefits to fewer employees. The necessary result will be more Americans without any health care coverage at all—a guaranteed prescription for lower quality overall care."