Health Maintenance Organizations Are Not "Fiduciaries" under Erisa, Says Unanimous Supreme Court
美国最高法院一致裁定，健康维护组织（HMO）在做出医疗决定时，不构成《雇员退休收入保障法》（ERISA）下的受托人，推翻了第七巡回上诉法院的判决。
Pegram v. Herdrich, 68 U.S. L.W. 4501, 2000 U.S. LEXIS 3964 (June 12, 2000) When Cynthia Herdrich experienced groin-area pain, she consulted Dr. Lori Pegram, a physician in Carle Health Insurance Management Company's Caale Clinic. Diagnosis revealed a six- to eight-centimeter inflamed mass in Herdrich's abdomen. Despite the noticeable inflammation, Dr. Pegram did not order an ultrasound diagnostic procedure at a local hospital, but decided that Herdrich would have to wait eight more days for an ultrasound, to be performed at a facility staffed by Carle more than 50 miles away. Before the eight days were over, Herdrich's appendix ruptured, causing peritonitis. 2000 U.S. LEXIS at *8-*9, citing to Court of Appeals opinion reciting facts, 154 F.3d 362,365 (7th Cir. 1998). Herdrich then sued Pegram and Carle in Illinois state court, alleging medical malpractice and fraud. The defendants contended that the Employee Retirement Income Security Act (ERISA) preempted the fraud counts and removed to federal court, obtaining dismissal of one fraud count. The other fraud count survived in amended form as a claim that the Carle HMO was liable to Herdrich under ERISA for breaching its duty to Herdrich. Herdrich argued that, since the health benefits and contract with the Carle HMO were part of the State Farm employee benefit plan (Herdrich's husband was a State Farm employee, and she was a dependent covered under the plan), the HMO was a under the plan, administering the healthcare benefits by making determinations of coverage eligibility and type of treatment required. According to Herdrich's theory of the case, the HMO committed breach and constructive fraud by having an arrangement that rewarded its physician owners for limiting medical and that this entailed an inherent or anticipatory breach of an ERISA duty, since these terms created an incentive to make decisions in the physicians' self-interest, rather than the exclusive interests of plan participants. 2000 U.S. LEXIS 3964 at *8. Specifically, Herdrich sought relief under 29 U.S.C. [sections]1109(a), the part of ERISA that provides that person who is a with respect to a plan who breaches any of the responsibilities, obligations, or duties imposed upon fiduciaries by this subchapter shall be personally liable... [and] subject to such other equitable or remedial relief as the court may deem appropriate, including removal of such duty. Herdrich argued that, because the HMO worked for the employee benefit plan and its members, making eligibility and treatment determinations, the HMO was acting as a fiduciary under ERISA. Herdrich contended that the HMO breached its duties to the patient and plan member by creating financial incentives for Dr. Pegram and others to provide reduced treatment, inferior treatment, or disincentives to treatment--all so that the HMO could be more profitable. The trial court initially rejected Herdrich's ERISA-based claim but a panel of the Seventh Circuit found the claim permissible. The three-judge panel reasoned that, by controlling access to the valuable healthcare offered under the plan, the HMO was essentially acting as a plan administrator. Under ERISA, plan administrators are considered fiduciaries who owe the plan members the highest duty of care and must place the interests of the plan member ahead of their own. The claim against the HMO alleged that Carle was favoring its own interests in profit ahead of the plan members' health interests. When the defendants petitioned for rehearing before the entire Seventh Circuit, the court was very divided but did not disturb the panel's decision. The appellate court judges dissenting from the denial of rehearing argued that the HMO did not administer the employee benefit plan but was merely a vendor working for the plan and plan members concerning the healthcare component of the plan. …