## Facts

- Joseph V. DiFelice, Jr. participated in an ERISA-governed employee welfare benefit plan administered by Aetna U.S. Healthcare as an HMO.
- Plan coverage was limited to “Covered Benefits” and generally required Aetna to determine that requested care was “Medically Necessary.”
- In March 2001, DiFelice was diagnosed with sleep apnea and upper airway obstruction and received a tracheostomy tube surgically placed by his treating otolaryngologist.
- The tube repeatedly became dislodged; the physician sought Aetna authorization for a specially designed tracheostomy tube.
- DiFelice alleged Aetna deemed the specialized tube “medically unnecessary,” refused authorization, and he received an alternative tube that caused severe pain and infection.
- DiFelice was later hospitalized; he alleged Aetna insisted on discharge before his attending physician believed discharge was appropriate.
- DiFelice sued in Pennsylvania state court, asserting state-law negligence against Aetna for (1) refusing the specialized tube and (2) insisting on premature discharge, along with additional claims against other medical defendants.
- Aetna removed to federal court, asserting complete preemption under ERISA § 502(a); the district court dismissed the Aetna negligence claim as completely preempted and remanded the remaining claims.

## Issues

1. Whether a negligence claim challenging Aetna’s “medical necessity” determination for a specialized tracheostomy tube is completely preempted by ERISA § 502(a) and removable.
2. Whether a negligence claim alleging Aetna insisted on premature hospital discharge is completely preempted by ERISA § 502(a) or instead remains a state-law medical-negligence/utilization-review claim.

## Decision

- The Third Circuit affirmed in part and reversed in part.
- The claim based on Aetna’s refusal to authorize the specialized tube as “medically unnecessary” was a benefits-eligibility/coverage dispute within ERISA § 502(a) and thus completely preempted; dismissal was affirmed.
- The claim based on Aetna’s alleged insistence on premature discharge concerned interference with medical care (quality of treatment) and was not completely preempted; the district court’s contrary treatment was reversed.
- The case was remanded with instructions to return the non-preempted early-discharge claim to state court.

## Legal Principles

- A state-law claim is completely preempted (and removable) when it falls within ERISA § 502(a)’s civil enforcement scheme, including claims that could be brought as actions to recover benefits or enforce plan rights.
- Challenges to plan-based “medical necessity” determinations that define whether a requested service or device is covered are treated as benefits-eligibility/plan-administration disputes and are completely preempted.
- Claims directed at the quality of care—such as negligent utilization review or discharge pressure that allegedly interferes with a physician’s medical judgment—are generally not recharacterizable as ERISA § 502(a) benefits claims and therefore are not completely preempted (even if related to managed-care cost controls).
- On a motion to dismiss, plan documents integral to the coverage allegations may be considered without converting the motion into one for summary judgment.

## Conclusion

The Third Circuit held that ERISA § 502(a) completely preempted DiFelice’s negligence claim to the extent it challenged Aetna’s plan-based medical-necessity coverage decision, but not to the extent it alleged negligent interference with medical judgment through an early-discharge demand; only the former was properly treated as an ERISA claim in federal court.


DiFelice v. Aetna U.S. Healthcare, 346 F.3d 442 (3d Cir. 2003)