Wk. Mariner, LIABILITY FOR MANAGED CARE DECISIONS - THE EMPLOYEE RETIREMENT INCOMESECURITY ACT (ERISA) AND THE UNEVEN PLAYING FIELD, American journal of public health, 86(6), 1996, pp. 863-869
As managed care organizations expand their programs of quality assuran
ce and physician evaluation, more medical malpractice lawsuits may be
brought against managed care organizations on the ground that, like ho
spitals, they are legally responsible for negligent corporate acts tha
t injure patients. However, the federal Employee Retirement Income Sec
urity Act (ERISA)shields managed care organizations from liability whe
n they are part of an employee group health plan governed by ERISA. Un
like patients with other types of Insurance, patients in ERISA health
plans do not have a malpractice remedy for a managed care organization
's negligence. A few federal appeals courts recently recognized that E
RISA plans can be vicariously liable for their physicians' medical mal
practice, but only if the physician is the plan's employee or agent. Y
et ERISA still prohibits negligence claims against ERISA health plans
for injuries resulting from denial of plan benefits, failure to use qu
alified physicians, utilization review, or improper plan administratio
n. Current managed care operations do not neatly distinguish between a
dministering benefits and controlling quality of care. Neither should
the law. ERISA should be amended to provide employees with the same re
medies that patients in non-ERISA plans enjoy.