WASHINGTON - Patients cannot sue health maintenance organizations under state law for refusing to pay for doctor-recommended care, the U.S. Supreme Court ruled on Monday in a decision that could affect millions of Americans.
The justices unanimously ruled that a 1974 federal law, the Employee Retirement Income Security Act, completely pre-empted such lawsuits brought in state court by patients who seek damages from their HMOs over the denial of medical care.
The state laws have become important as Congress has failed to adopt national legislation that would allow patients to sue their health maintenance organization in a federal court for medical malpractice.
The Supreme Court decision involved a law, in President Bush's home state of Texas, that allowed patients to sue HMOs over their medical treatment.
The court's decision has election-year political overtones.
Democratic presidential candidate Sen. John Kerry said the ruling showed a need for a national law to "hold HMOs accountable for decisions that harm patients by denying necessary care."
Democrats criticized the U.S. Justice Department for opposing the Texas law before the high court. They said Bush, who was Texas' governor when the law took effect in 1997, had supported it during his 2000 presidential campaign.
The decision was a victory for insurers, which have warned that allowing the lawsuits would drive up health-care costs. Millions of Americans participate in employer-provided HMO health plans governed by the 1974 federal law.
At least nine other states -- Arizona, California, Georgia, Maine, New Jersey, North Carolina, Oklahoma, Washington, and West Virginia -- have laws similar to the Texas one.
George Parker Young, an attorney for two patients who sued, urged Bush and Congress to renew a commitment to pass a patient's bill of rights.
Ron Pollack, executive director of the consumer group Families USA, blasted the ruling as a blank check for HMOs to deny care.
'SAD DAY FOR PATIENTS, PHYSICIANS'
American Medical Association President John Nelson said, "This is a sad day for America's patients and the physicians who care for them."
Insurers applauded the decision. Aetna Inc., which had been sued in one of the cases, said, "The court has helped to assure that millions of working Americans will continue to have access to quality health coverage provided by their employers."
Karen Ignagni, president of the industry group America's Health Insurance Plans, said, "This ruling puts the brakes on efforts by trial lawyers to turn every question about the scope of an individual's coverage into a costly lawsuit."
The two cases involved units of Aetna and Cigna Corp. . One lawsuit had been brought by Juan Davila, who was covered through his employer by an Aetna health maintenance organization.
In 2000, Davila's doctor prescribed the pain-killer "Vioxx" for his arthritis. Aetna required Davila to try two less-expensive medications before it would fill the prescriptions.
After three weeks on the cheaper pain reliever, Davila was rushed to the emergency room, suffering from bleeding ulcers.
The other lawsuit involved Ruby Calad, who was discharged from the hospital in 1999 after a hysterectomy. Cigna's nurse decided the company would pay only for the standard one-day hospital stay, although Calad's doctor had recommended a longer stay.
Several days after her release, Calad suffered complications. She then sued.
In an opinion by Justice Clarence Thomas, the justices reversed a U.S. appeals court ruling that the two lawsuits could proceed.
Additional reporting by Kim Dixon in Chicago
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