Naked City

Supremes spike Texas HMO law

A unanimous U.S. Supreme Court on June 21 ruled that two Texans do not have the right to sue their HMOs over coverage denials under state law, and instead must make their legal challenge under federal law. In March, the high court heard arguments in two consolidated Texas cases – Aetna Health v. Davila and CIGNA Corp. v. Calad – in which patients sued the nation's No. 3 and No. 4 health insurers under the 1997 Texas Health Care Liability Act, charging that the companies discounted their doctors' medical advice and made medical judgements based solely on coverage concerns. Aetna appealed a U.S. 5th Circuit Court of Appeals ruling that the patients had the right to sue under the state law, arguing that provisions of the federal Employee Retirement Income Security Act of 1974, which requires health plan managers to set up a grievance and appeal process for consumers, pre-empt the THCLA. The ERISA rules also limit insurers' liability to the actual cost of denied treatment, even if the consequences include disability or death.

On Monday the high court, in an opinion written by Justice Clarence Thomas, agreed that challenges to an HMO's administration decision-making must pass through the ERISA process, which was (in Thomas' view) designed specifically to create a single, federal regulatory system for insurers that pre-empts state law. In a January amicus brief to the court, Texas Attorney General Greg Abbott argued on behalf of 19 states that forcing cases through the ERISA process insulates HMOs from liability by denying patients access to stricter and more patient-friendly state laws (and more plaintiff-friendly state courts).

That position is seemingly supported by at least two high court justices. In a concurring opinion, Justice Ruth Bader Ginsburg (joined by Justice Stephen Breyer) urged Congress to "revisit what is an unjust and increasingly tangled ERISA regime." While ERISA may have legal precedence in these cases, its "cramped construction" has created a regulatory black hole. "A series of the Court's decisions has yielded a host of situations in which persons adversely affected by ERISA-proscribed wrongdoing cannot gain make-whole relief," she wrote.

In Other Supreme Court News:

On June 21 the court narrowly (5-4) upheld a Nevada law allowing police to arrest citizens who fail to identify themselves. Rancher Larry Hiibel was arrested for violating the Silver State's stop-and-identify law when he refused to give his name to an officer investigating a reported assault nearby. Hiibel challenged his arrest but was shot down by the lower courts and now by the Supremes, who ruled the officer's "reasonable suspicion" was enough to justify his request.

Previous stop-and-identify laws had been thrown out on constitutional grounds – including a 1979 Texas case where the court ruled that two El Paso officers violated the rights of a man who was jailed after police stopped him for looking "suspicious." But the Hiibel case "begins where prior cases left off," Justice Anthony Kennedy wrote for the majority, adding that having the ability to ask questions, the majority opined, "is an essential part of police investigations."

Four justices disagreed, arguing that the court should refrain from carving "special circumstances" out of the essential rights against unlawful search and self-incrimination. In one of two dissents, Justice John Paul Stevens opined that "the Fifth Amendment's guarantee [against self-incrimination] ... does not admit even the narrow exception defined by the Nevada statute." And Breyer (joined by justices Ginsburg and David Souter) argued that defining narrow exceptions to the Fourth and Fifth Amendments will muddy the legal waters: "Can a State ... also require an answer to 'What's your license number?' or 'Where do you live?'" he asked. "Can a police officer ... keep track of the constitutional answers? After all, answers to any of these questions may, or may not, incriminate, depending upon the circumstances." Currently, Texas has no stop-and-identify law: Officers may not require identification unless a person is already under arrest.

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