Rush Prudential Hmo, Inc. v. Debra C. Moran et al. (536 U.S. 355)
U.S. Supreme Court · decided June 20, 2002 · Supreme Court Database (Spaeth)
- Citation
- 536 U.S. 355 · 122 S. Ct. 2151
- Decided
- June 20, 2002
- Term
- October Term 2001
- Vote
- 5–4
- Majority author
- Justice Souter
- Issue area
- Federalism
- Disposition
- Affirmed
- Outcome
- Petitioning party lost
- Ideological direction
- Conservative
Opinion excerpt
Justice Souter delivered the opinion of the Court. Section 4-10 of Illinois’s Health Maintenance Organization Act, 215 Ill. Comp. Stat., ch. 125, §4-10 (2000), provides recipients of health coverage by such organizations with a right to independent medical review of certain denials of benefits. The issue in this ease is whether the statute, as applied to health benefits provided by a health maintenance organization under contract with an employee welfare benefit plan, is preempted by the Employee Retirement Income Security Act of 1974 (ERISA), 88 Stat. 832, as amended, 29 U. S. C. § 1001 et seq. We hold it is not. I Petitioner, Rush Prudential HMO, Inc., is a health maintenance organization (HMO) that contracts to provide medical services for employee welfare benefit plans covered by ERISA. Respondent Debra Moran is a beneficiary under one such plan, sponsored by her husband’s employer. Rush’s “Certificate of Group Coverage,” issued to employees who participate in employer-sponsored plans, promises that Rush will provide them with “medically necessary” services. The terms of the certificate give Rush the “broadest possible discretion” to determine whether a medical service claimed by a beneficiary is covered under the certificate. The certificate specifies that a service is covered as “medically necessary” if Rush finds: “(a) [The service] is furnished or authorized by a…
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