Claims allege that a plan's denial of authorization or coverage caused injury by delaying or preventing necessary treatment. Theories include negligence in utilization review, vicarious liability for plan physicians, and bad faith.
ERISA preemption limits most claims against employer plans.
Alternative Names:
MCO Liability, Health Plan Liability
Why it Matters?
ERISA preemption is the defining constraint, since claims against employer-sponsored plan administrators are generally confined to recovery of the denied benefit without consequential or punitive damages. The distinction courts draw is between benefit determinations, which are preempted, and medical treatment decisions, which may not be. Plans structuring utilization review as coverage rather than treatment decisions preserve the preemption defense.
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Frequently asked questions
What limits managed care liability claims?
What distinction do courts draw?
