Land v. CIGNA Healthcare of Florida

[Belgarath]

I deal with qualified retirement plans, so my question here is purely as a consumer. The 11th circuit U.S. Court of Appeals barred a participant's state malpractice claims, and instead said that it falls under ERISA.

The physician recommended treatment was denied by a CIGNA HMO "approval nurse," who allowed the use of the recommended antibiotic, but denied hospital admission and said that it must be treated on an out-patient basis. Bad things then ensued.

For regular people - what are the implications of this? If justified, who could you sue, and for what? Is this decision sort of anti-consumer, or is it relatively neutral, and just requires a suit in a different venue? Does it really limit your recourse, or just sort of change it?

Just curious - not planning on any lawsuits! Thanks.

[Don Levit]

I remember reading about that case, and will only provide material from my sketchy recollection. The plan was an ERISA plan, and ERISA has exclusive rights regarding claims disputes. By that, I mean that no damages can be awarded above the amount of the claim that was denied.

This decision was seen as an eligibility question, rather than a medical decision by the HMO. If I remember correctly, the physician was not an employee of the HMO, so there was no conflict of interest. If there was a conflict of interest, the decision may have been viewed as one of mixed eligibility and medical necessity, thus allowing potentially extra damages, in addition to the claim denied.

Don Levit