In a ruling likely to influence similar cases around the nation, a federal appeals court has ruled that the widow of a man whose HMO denied him necessary treatment can sue the HMO for medical malpractice.
Carmine Cicio was diagnosed with multiple myeloma, a form of blood cancer. In 1998, Mr. Cicio''s oncologist wrote a letter to Mr. Cicio''s HMO, Vytra Healthcare, seeking approval to treat him with and a double infusion of Mr. Cicio''s own stem cells, called a double stem cell transplant. This procedure, the oncologist said, was "a well-established method of treatment" that offered a better chance of survival than any other therapy. Vytra''s medical director denied the request, saying double stem cell transplant was an experimental procedure and not covered by Mr. Cicio''s health care plan. Mr. Cicio died less than two months later.
Mr. Cicio''s widow, Bonnie, sued Vytra and its medical director in state court for medical malpractice. In 2001, a U.S. district court ruled that Mrs. Cicio could not sue in state court because her claims were preempted by the federal Employee Retirement Income Security Act of 1974 (ERISA). ERISA supersedes all state laws that relate to employee benefit plans. The district court ruled that all of Mrs. Cicio''s claims centered on Vytra''s refusal to approve coverage and thus were preempted by ERISA because they related to her husband''s eligibility under his employee benefit plan. Mrs. Cicio appealed.
The U.S. Court of Appeals for the Second Circuit disagrees with the lower court, ruling that Mrs. Cicio may sue the HMO in state court. At one time, the court notes, such suits would have been blocked by ERISA because courts saw "eligibility" decisions and "treatment" decisions as two separate things. But the court notes that the U.S. Supreme Court in Pegram v. Herdrich 530 U.S. 211, 229 (2000) "established a new framework" for examining such cases by introducing the concept of "mixed eligibility and treatment decisions." When HMOs make this type of decision, the court says, they are both interpreting an insurance contract and exercising their medical judgment on how to treat the patient. In doing so, the court goes on, they are no longer making decisions that have only to do with an employee benefit plan and therefore are not shielded by ERISA. In such cases, they may be sued for medical malpractice if their treatment decisions are allegedly flawed.
The ruling applies only in New York, Connecticut and Vermont, but "the opinion is likely to influence judges in other parts of the country because it comes from a respected court and provides a comprehensive analysis of H.M.O. liability after several recent Supreme Court decisions," according to The New York Times.
For the full article in The New York Times on the decision, go to: https://www.nytimes.com/2003/02/18/health/18HEAL.html (Article may be only temporarily available.)
For the full text of the decision, Cicio v. Vytra Healthcare (2nd Cir., No. 01-9248, Feb. 11, 2003), go to: https://law.touro.edu/2ndcircuit.
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