This was something I had thought about when discussing denials of coverage but never looked into (not that it matters much to me since nothing I order in the hospital gets denied). In Aetna Health Inc. v. Davila, 542 U.S. 200 (2004), Respondents both suffered injuries allegedly arising from Aetna’s and CIGNA’s decisions not to provide coverage for certain treatment and services recommended by respondents’ treating physicians. Davila’s treating physician prescribed Vioxx to remedy Davila’s arthritis pain, but Aetna refused to pay for it. Davila did not appeal or contest this decision, nor did he purchase Vioxx with his own resources and seek reimbursement. Instead, Davila began taking Naprosyn, from which he allegedly suffered a severe reaction that required extensive treatment and hospitalization. Calad underwent surgery, and although her treating physician recommended an extended hospital stay, a CIGNA discharge nurse determined that Calad did not meet the plan’s criteria for a continued hospital stay. CIGNA consequently denied coverage for the extended hospital stay. Calad experienced postsurgery complications forcing her to return to the hospital. She alleges that these complications would not have occurred had CIGNA approved coverage for a longer hospital stay. Apparently under ERISA (Employee Retirement Income Security Act of 1974), state law claims that conflict with federal employee benefit rules are "preempted" (overridden) such that patients cannot sue employer-sponsored health plans for tort damages (such as pain, suffering, lost wages, or wrongful death) resulting from a bad coverage decision. Exceptions to ERISA preemption include any insurance not subsidized by a private employer individual health plan policies or self-paid plans government employee plans (insurance provided to federal, state, or local government employees) church-sponsored plans government programs (Medicare, Medicaid, VA) I don't know what the takeaway is: don't get employer-sponsored plans?   submitted by   /u/princetonwu [link]   [comments]