Appeals Court: ERISA Bars HMO Suit

December 31, 2002 ( - Lawsuits against health maintenance organizations over the designation of a doctor as a primary care physician are barred by ERISA, a federal appeals court ruled.

That means that Charles Haynes Jr.’s family can’t sue an HMO after it refused to let his doctor treat his leg, according to a ruling from the US 5th Circuit Court of Appeals, the National Law Journal reported.

Haynes, a diabetic Mississippi resident who died in April 2001, lost part of his leg after the HMO insisted that the doctor at a wound-care center where he went for treatment was not a primary physician in Prudential PruCare’s system.

According to the National Law Journal Report, Haynes began suffering painful swelling in his right foot and lower leg in October 1999. His doctor rushed him to the wound care center and the doctor’s staff tried to arrange to care for him.  But PruCare refused to let Haynes be treated at the center, saying he needed a referral from an approved primary doctor, according to court documents quoted by the National Law Journal story.  The Law Journal story said that PruCare provided three telephone numbers. One was disconnected; one reached an answering machine; and calls to the third were not returned.

Untreated Infection

Meanwhile, the untreated infection raged on for a week longer. His leg so swollen that his toes burst; Haynes was taken to an emergency room, where he was assigned a PruCare doctor. After medical treatment failed, PruCare approved amputating the lower right leg.

Haynes had been told the leg could have been saved if it had been treated in time, the court said. Haynes 2001 death was from unrelated causes.

According to the Law Journal, Haynes filed suit in a Mississippi federal court, claiming the delayed treatment caused his injury. PruCare asked a judge to throw out the suit, saying the claim is preempted by ERISA because the decision was administrative, not medical in nature. The trial judge agreed and Haynes’ widow, Geneva, appealed.

The 5th Circuit upheld the lower court.

Previous Preemptions

In September, a Fifth Circuit upheld a decision by US District Judge Sidney Fitzwater of Dallas that ERISA pre-empted a patient suit.(See  Texas Court May Rethink HMO ERISA Preemption ).

The suit was filed on behalf of a woman whose left leg had to be amputated because her HMO allegedly delayed and denied special treatments ordered by her doctor after she underwent skin graft operations and surgeries to create flaps over wounds caused by a spider, according to the report

The Fifth Circuit ruled earlier in December that ERISA doesn’t negate a Texas law calling for independent review of HMO rules. (See Fifth Circuit Court Reverses Earlier ERISA Preemption Ruling ).