Ethics Newsline®

WASHINGTON
People who suffer harm after their HMO refuses to cover medical care recommended by their doctor cannot be sued for damages, the Supreme Court ruled last week, noting that Congress has so far refused to authorize that right.

In a unanimous ruling, the court invalidated lawsuits filed by two Texans rushed to the hospital for emergencies after foregoing doctor-recommended care denied them by their health insurance companies — Cigna and Aetna.

In its decision, the court said that ERISA, a 30-year-old federal law governing employee benefits like health insurance, allows lawsuits for recovering only costs, not punitive damages, as were sought in the cases brought before the Supreme Court.

Since ERISA trumps any other laws, even state laws designed to allow punitive suits, the plaintiffs have no other recourse, the justices agreed, according to the New York Times.

The decision leaves no avenue of appeal for the two plaintiffs: Ruby Calad, who was rushed back to the hospital after being sent home, against her doctor’s recommendation but in accord with her Cigna health plan, one day after a hysterectomy; and Juan Davila, who suffered massive internal bleeding after his Aetna plan forced him to take a cheaper drug than the one recommended by his doctor.

While both patients could have sued to recover only the costs of the denied treatments — the price of a slightly longer hospital stay or the more expensive pills — ERISA prevents them from seeking damages for the injuries and trauma they suffered.

Echoing the HMO industry’s claims, Justice Clarence Thomas contended that the problem was not caused by Cigna and Aetna, but by the plaintiffs’ employers, who declined to pay for the HMOs’ more expensive plans that might have covered the recommended treatments.

The American Medical Association said it was “extremely disappointed” with the court’s decision.

Last week’s ruling puts the spotlight squarely on Congress, which so far has failed to pass a so-called patient’s bill of rights giving people the right to sue when needed medical care is not covered by their employer’s health-care plans. More than 130 million Americans are enrolled in such plans.

“A regulatory vacuum exists,” said Justice Ruth Bader Ginsburg.