Can Plan Administrator be Considered `Treating' Physician?(Brief Article)

CASE ON POINT: Hull v. Fallon, 185 F.3d 939 - MO (1999)

ISSUE: Patients are being denied diagnostic tests, operative procedures, physiotherapy and other necessary treatment because of economics. We have entered into an era in which the patient's health care insurer virtually has carte blanche to dictate whether diagnostic tests will be performed, how frequently they will be performed, whether surgery will be performed, delayed, or not performed at all. This has led to an unacceptable level of care and treatment or, more appropriately, a lack of care and treatment. How long will we tolerate allowing health care insurers to dictate how medicine will be practiced? Federal laws have preempted state courts from holding health care insurers responsible for what some perceive to be near-criminal conduct.

CASE FACTS: Jeffrey Hull was an employee of Prudential Insurance Company, and participated in a health insurance plan issued by Prudential Health Care Plan, Inc. (the Plan), an employee welfare benefit under the Employee Retirement Income Security Act (ERISA). In January 1996, Hull went to Dr. Delcau, his primary care physician, complaining of shortness of breath chest pain and arm pain. Dr. Delcau was a member physician of the Plan. The patient alleges that on two occasions, once in January, and again in February, Dr. Delcau contacted Dr. Fallon, the Plan's administrator, regarding his diagnosis and treatment plan for him, requesting authorization to administer a thallium stress test. Dr. Fallon denied both requests for a thallium stress test and instead authorized a treadmill stress test. The patient alleges that, as a result of the denial of the thallium test, he suffered a myocardial infarction and developed additional heart disease. The patient sued for medical malpractice in Missouri, alleging that Dr. Fallon, the Plan administrator, failed to exercise a sufficient degree of care in diagnosing and treating him. The patient also alleged that the Plan was vicariously liable for Dr. Fallon's alleged negligence. Dr. Fallon and the Plan filed a notice of removal to federal district court, arguing that the patient's claims were preempted by ERISA, thus creating federal question jurisdiction. A motion to dismiss for failure to state a claim under ERISA was also filed. The United States District Court for the Eastern District of Missouri denied the patient's motion to remand the case back to the state court and granted the defendants' motion to dismiss. The patient appealed.

COURTS OPINION: The United States Court of Appeals, Eighth Circuit, affirmed the judgment of the lower court. The court held that the patient's claims were completely preempted by ERISA. The court held that ERISA completely preempted the patient's claim against the Plan's administrator, arising from the ...