HLD, v. 32, n. 11 (November 2004)
U.S. Court In Louisiana Dismisses ERISA Action, State Law Claims
Against Healthcare Providers
An enrollee of a health plan governed by the Employee Retirement
Income Security Act (ERISA) could not maintain a claim under ERISA for wrongful
denial of benefits against her healthcare providers, a federal district court
in Louisiana ruled September 28. The court concluded that a health plan is the
only proper defendant in an ERISA action to recover benefits due under the plan.
The court also dismissed the enrollee's state law claims of breach of contract
and negligence levied against the healthcare providers as pre-empted by ERISA.
The court found these claims stemmed from an ERISA plan and could only be resolved
by reference to the plan.
Carolyn Cuccia had health insurance coverage through an ERISA-governed
employee group medical plan issued by Aetna Insurance Company (Aetna). Cuccia,
who was morbidly obese, was receiving treatment from Weight Management Center,
St. Charles General Hospital, and Tenet Healthcare (collectively Tenet defendants).
According to Cuccia, she informed the Tenet defendants that she met Aetna's
requirements for gastric bypass surgery. Cuccia claims that the Tenet defendants
failed to submit the required documentation to Aetna in a timely manner and
then failed to respond to the health plan's request for more information. By
the time the surgery was scheduled, Cuccia was no longer covered by Aetna. Cuccia
eventually paid for the $24,000 procedure on her own.
Cuccia sued Aetna, her employer, and the Tenet defendants, alleging
she had wrongfully been denied healthcare benefits under ERISA. Cuccia also
asserted pendant state law claims of breach of contract, detrimental reliance,
negligence, fraud, deceptive trade practices, and other common law causes of
action not pre-empted by ERISA. The Tenet defendants moved to dismiss.
The U.S. District Court for the Eastern District of Louisiana granted
the motion, concluding that Cuccia had no remedy against the Tenet defendants.
First, the court held that a health plan is the only proper defendant in a claim
for benefits under ERISA. "Although the Fifth Circuit has not yet addressed
the issue, other district courts in this circuit have agreed that the only proper
defendant in a suit to recover benefits is the plan," the court wrote. Thus,
Cuccia could not maintain an ERISA claim against the Tenet defendants.
Next, the court concluded that ERISA pre-empted Cuccia's remaining
state law claims. Citing the U.S. Supreme Court's recent decision in Aetna
Health Inc. v. Davila, 124 S.C. 2488 (2004), the court found that Cuccia's
state law claims fell "within the scope" of ERISA's civil enforcement provision.
Cuccia alleged that the Tenet defendants' failure to submit the required documentation
to Aetna in a timely manner resulted in the wrongful denial of benefits due
to her. Such claims are pre-empted by ERISA, the court held. The court rejected
Cuccia's contention that her tort claims of negligence and detrimental reliance
were separate from her ERISA claims. Instead, the court held that Cuccia's claims
derived from the healthcare benefits plan as the court would have to look to
the plan to determine whether a negligent breach had occurred.
Finally, the court noted that Cuccia could still pursue her ERISA
� 502(a)(1)(B) claim against her employer and Aetna.
Cuccia v. Roberson Advertising Servs., Inc., No. Civ.A.
04-1293, 2004 WL 2186618 (E.D. La. Sept. 28, 2004).