Difelice v. Aetna U.S. Healthcare

346 F.3d 442
CourtCourt of Appeals for the Third Circuit
DecidedOctober 15, 2003
Docket02-3381
StatusPublished
Cited by41 cases

This text of 346 F.3d 442 (Difelice v. Aetna U.S. Healthcare) is published on Counsel Stack Legal Research, covering Court of Appeals for the Third Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

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

Opinions

OPINION OF THE COURT

RENDELL, Circuit Judge.

We are once again called upon to determine whether a lawsuit claiming medical negligence is completely preempted by the civil enforcement provision of the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1132(a). Joseph V. DiFeliee, Jr., appeals the order of the United States District Court for the Eastern District of Pennsylvania dismissing his complaint against Aetna/U.S. Healthcare, Inc. (“Aetna”) for negligent conduct in regard to his medical treatment for sleep apnea and upper airway obstruction. DiFeliee filed suit in state court, alleging that Aetna’s instruction to his treating physician that a specially designed tracheosto-my tube was “medically unnecessary” and Aetna’s insistence that he be discharged from the hospital before his attending physician deemed it appropriate amounted to negligent conduct under state law. Aetna removed the ease to federal court on the basis of ERISA preemption and then moved to dismiss the claim. The District Court, relying on our decision in Pryzbowski v. U.S. Healthcare, Inc., 245 F.3d 266 (3d Cir.2001), held that the claim was completely preempted and dismissed it in its entirety. For the reasons that follow, we will affirm in part and reverse in part.

I.

DiFeliee participates in an ERISA-gov-erned employee welfare benefit plan that is administered by Aetna, a health maintenance organization (“HMO”). Under the terms of this plan, DiFeliee is entitled to certain “Covered Benefits.” Unless there is a specific provision for a particular type of treatment, a benefit is only covered if, in the determination of Aetna, it is “Medically Necessary.” “Medically Necessary” is a defined term, meaning the service or supply must be “care or treatment as likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any alternative service or supply;” must be “related to diagnosis of an existing illness or injury;” may “include only those services and supplies that cannot be safely and satisfactorily provided at home;” and, “as to diagnosis, care and treatment[, must] be no more costly (taking into account all health expenses incurred in connection with the service or supply) than any equally effective service or supply.”

In March 2001, DiFeliee was diagnosed with “sleep apnea/upper airway obstruction,” for which he required a tracheosto-my tube.1 His doctor, Dr. Michael Picar-iello, surgically inserted a tracheostomy tube to eliminate the obstruction, but that tube continually came out. Dr. Picariello then placed an order for a specially designed tube. However, Aetna instructed Dr. Picariello that the special tube was “medically unnecessary.” Instead of ordering the special tube, the doctor then inserted a different tube, which caused DiFeliee severe pain and resulted in an infection. DiFeliee was later admitted to Chester County Hospital for treatment, but, the complaint avers, was thereafter discharged “at Aetna’s insistence.”2

[445]*445DiFelice filed a five-count complaint in the Philadelphia Court of Common Pleas against Aetna, his treating physicians, and the hospital. In Count I, he alleged that Aetna negligently interfered with his medical care “by instructing Dr. Picariello that the specially designed tracheostomy tube he deemed necessary was medically unnecessary for [DiFelice] and improperly interfering with Dr. Pieariello’s medical decision concerning the tracheostomy tube and insisting on [DiFelice’s] discharge from the [hospital] ... before his attending physician was planning on discharging [him].” The other counts involved claims against parties other than Aetna. Aetna removed the case to the District Court on the grounds that the claim against it was completely preempted under ERISA and then moved to dismiss. DiFelice opposed the motion to dismiss and moved to remand to state court.

The District Court denied DiFelice’s motion to remand and granted Aetna’s motion to dismiss as to Count I, and granted the motion to remand on the remaining counts against the other parties. The Court held that the disposition of Count I was “squarely controlled by the Third Circuit’s decision in Pryzbowski, ” in which we held that a claim challenging the “administration of or eligibility for benefits” was completely preempted by section 502(a)(1)(B) of ERISA. Pryzbowski, 245 F.3d at 273. The Court reasoned that the claim against Aetna was completely preempted because DiFelice was challenging Aetna’s decision that he was not entitled to the special tube under the Plan, which was entirely a matter of administration, and because Aetna was not actually involved in providing any medical services to DiFelice. DiFelice appeals the District Court’s order dismissing Count I.

II.

We have jurisdiction over the District Court’s final order pursuant to 28 U.S.C. § 1291, and review the Court’s exercise of jurisdiction and order of dismissal de novo. Pryzbowski, 245 F.3d at 268. Aetna bears the burden of proving the federal jurisdiction it seeks. Spectacor Mgt. Group v. Brown, 131 F.3d 120, 127 (3d Cir.1997). In reviewing the complaint, we must accept as true all of DiFelice’s factual allegations and draw all reasonable inferences therefrom. Langford v. City of Atlantic City, 235 F.3d 845, 847 (3d Cir.2000).

DiFelice challenges the District Court’s removal jurisdiction over Count I of his complaint and asks us to remand to state court. He argues that his negligence action against Aetna is entirely a matter of state law and provides no basis for removal. Aetna counters that DiFelice’s negligence action is in fact nothing more than an action to recover benefits due under his plan, and as such is completely preempted by the civil enforcement provision of ERISA, section 502(a).

A. Framework

Under the “well-pleaded complaint” rule, federal question jurisdiction only exists where an issue of federal law [446]*446appears on the face of the complaint. Franchise Tax Bd. of Cal. v. Const. Laborers Vacation Trust for S. Cal., 463 U.S. 1, 24, 103 S.Ct. 2841, 77 L.Ed.2d 420 (1983). However, there is an exception to this rule: when a purportedly state-law claim “comes within the scope of [an exclusively] federal cause of action,” it “necessarily ‘arises under’ federal law,” and is completely preempted. Id.; see also Beneficial Nat’l Bank v. Anderson, — U.S. —, 123 S.Ct. 2058, 2062, 156 L.Ed.2d 1 (2003) (explaining the preemptive effect of ERISA). The question before us is therefore whether DiFeliee’s claims of state law negligence on the part of Aetna fall within the scope of the federal causes of action provided in section 502(a) of ERISA, that is, whether the claims could have been brought under that section. If so, then the existence of the federal claim would provide the basis for federal question jurisdiction but at the same time would require dismissal based on complete preemption.

We have had numerous occasions to consider the question of whether a plaintiffs claim against an HMO is covered by section 502(a) and is therefore completely preempted. See, e.g., Pryzbowski, 245 F.3d at 273-75; Lazorko v. Pa. Hosp.,

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Bluebook (online)
346 F.3d 442, Counsel Stack Legal Research, https://law.counselstack.com/opinion/difelice-v-aetna-us-healthcare-ca3-2003.