## Facts

- Juan Davila and Ruby R. Calad were enrolled in employer-sponsored health plans administered by Aetna and CIGNA and governed by the Employee Retirement Income Security Act of 1974 (ERISA).
- Each sought coverage for certain medical services under plan terms; the HMOs refused to provide the requested coverage.
- Respondents sued in Texas state court under the Texas Health Care Liability Act (THCLA), alleging the HMOs failed to exercise “ordinary care” in making health care treatment decisions and that the refusals proximately caused injuries.
- Petitioners removed the cases to federal court, asserting the THCLA claims were completely preempted by ERISA’s civil enforcement provision, ERISA § 502(a).
- Federal district courts denied remand and dismissed with prejudice after respondents declined to replead as ERISA claims.
- The Fifth Circuit reversed, viewing the claims as outside ERISA § 502(a) because they involved “mixed eligibility and treatment decisions” and did not merely duplicate a claim for benefits.
- The Supreme Court granted certiorari and consolidated the cases.

## Issues

1. Whether THCLA causes of action seeking damages for injuries allegedly caused by an HMO’s refusal to cover treatment under an ERISA plan fall within ERISA § 502(a)(1)(B).
2. Whether such state-law claims are “completely preempted,” making them removable to federal court and governed exclusively by ERISA’s remedial scheme.
3. Whether the THCLA imposes an “independent legal duty” separate from plan-based duties that would avoid complete preemption.

## Decision

- The Supreme Court unanimously reversed the Fifth Circuit.
- The Court held that respondents’ THCLA claims fell within ERISA § 502(a)(1)(B) and were therefore completely preempted.
- Because the claims were completely preempted, removal to federal court was proper and the state-law causes of action could not proceed as pled.
- The Court distinguished prior cases relied on by the Fifth Circuit, concluding they did not limit § 502(a)(1)(B) in this setting.

## Legal Principles

- ERISA § 502(a) provides an exclusive federal cause of action; state-law claims that duplicate, supplement, or supplant ERISA’s civil enforcement remedy are preempted.
- A state-law claim is completely preempted by ERISA § 502(a)(1)(B) when (1) the plaintiff could have brought the claim under § 502(a)(1)(B), and (2) no other independent legal duty is implicated by the defendant’s conduct.
- Claims framed as negligence or statutory “duty of care” actions are treated by substance, not label; when they challenge plan coverage determinations and seek relief for wrongful denial of promised benefits, they fall within § 502(a)(1)(B).
- Pegram v. Herdrich, addressing fiduciary status and § 502(a)(2) in the context of physician treatment decisions, does not control the scope of § 502(a)(1)(B) for coverage-denial disputes.
- Rush Prudential HMO, Inc. v. Moran did not authorize state-law damages remedies that operate as alternatives to ERISA’s enforcement scheme for benefit-denial disputes.

## Conclusion

The Court held that ERISA § 502(a)(1)(B) completely preempts state-law THCLA claims seeking damages based on an HMO’s refusal to cover treatment under an ERISA plan, because the asserted duties and alleged injuries arise from plan-based benefit administration and implicate no independent legal duty.


Aetna Health Inc. v. Davila, 542 U.S. 200 (2004)