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A diabetic Mississippi man who lost part of his leg after his health maintenance organization refused to let his doctor treat him has posthumously lost his bid to sue the plan. The 5th U.S. Circuit Court of Appeals held on Dec. 9 that determining whether a doctor is a primary-care physician or not is an administrative, not medical, decision, and any suit challenging such determination is pre-empted by the Employee Retirement Income Security Act (ERISA). Haynes v. Prudential Health Care, No. 01-60801. The man, Charles Haynes Jr., had been treated for diabetes by a doctor for years. After his employer changed its health plan to Prudential’s “PruCare” in January 1999, he was still able to use the doctor as his primary physician, with PruCare paying the bills. In October 1999, Haynes began suffering painful swelling in his right foot and lower leg. His doctor rushed him to a wound care center and the doctor’s staff tried to arrange treatment. According to the court, PruCare refused to let Haynes be treated at the center, saying his doctor was not a PruCare primary-care physician. He needed a referral from an approved primary doctor. PruCare provided three telephone numbers. One was disconnected; one reached an answering machine; and calls to the third were not returned. Meanwhile, the untreated infection raged on for a week longer. His leg so swollen that his toes burst, Haynes was taken to an emergency room, where he was assigned a PruCare doctor. After medical treatment failed, PruCare approved amputating the lower right leg. Haynes was never able to return to work. He died from unrelated causes in April 2001. Haynes had been told the leg could have been saved if it had been treated in time, the court said. Before dying, he filed suit in a Mississippi federal court, claiming the delayed treatment caused his injury. PruCare moved to dismiss, saying the claim is expressly pre-empted by ERISA because the decision was not medical in nature. The trial judge agreed and Haynes’ widow, Geneva, appealed. Affirming, the 5th Circuit explained that ERISA pre-empts state law claims related to employee benefit plans but not areas reserved for state regulation, such as banking and insurance. ERISA also bars claims involving administrative decisions, such as whether to stop letting an unapproved doctor act as a primary physician. “Though the end result of Haynes losing part of his leg is tragic, his claim is based solely on the administration of his health benefits [which] is expressly preempted by ERISA,” the panel concluded. George Parker Young of Fort Worth, Texas, who represents Haynes’ widow, said it is important “for the pleadings to set the tone” that a plan made medical decisions — or a court may “narrowly focus” on administrative details and “gloss over” the medical effect of delaying, denying or altering prescribed treatment. Young said the full circuit may review the Oct. 31 decision by another panel in Roark v. Humana Inc., No. 01-10831, describing circuit law this way: “If the doctor recommends treatment, and the HMO denies coverage, the patient has no remedy. In this circuit, HMOs can escape all liability if they instruct their doctors to recommend every possible treatment and leave the real decision to plan administrators.” Young said he will ask for a rehearing while Roark is pending because the ruling may affect or “be meaningful” to Haynes. PruCare’s lawyer, John B. Shely of Houston’s Andrews & Kurth, could not be reached for comment.

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