Quick Summary: Congress did not intend the Employee Retirement Income Security Act to bar malpractice lawsuits against health insurers, health plans or health maintenance organizations for faulty patient care planning.    UNITED STATES DISTRICT COURT, ARIZONA, 1998.

   According to the U.S. District Court for the District of Arizona, following a landmark 1995 U.S. Supreme Court decision there is now a trend away from the idea that all patients’ and beneficiaries’ lawsuits against health plans are disallowed under the legal doctrine of Federal pre-emption under ERISA.

   The courts still stick to the rule that patients and beneficiaries do not have the right to file lawsuits in state or Federal court to challenge benefit schedules, internal management decisions and financial priorities. Those areas are still off-limits.

   What is new is a trend toward allowing patients and beneficiaries to sue health plans, insurance companies and health maintenance organizations for acts that can be characterized as medical-care decisions rather than administrative matters.

   A healthcare professional who plans a beneficiary’s health care while working for a health insurer, health plan or health maintenance organization and following its rules can commit malpractice and can be sued along with the health insurer, health plan or health maintenance organization, if the care plan falls below accepted professional standards, the court said. Moreno v. Health Plan, 4 F. Supp. 2d 888 (D. Ariz., 1998).