Straight Talk Covering Managed Care and ERISA Challenges

For over 30 years, Managed Care Litigation practice group at Hunton Andrews Kurth LLP has effectively influenced how managed care and ERISA cases are decided by the courts. Representing managed care companies, insurance companies and plan administrators, our lawyers have been at the forefront of this rapidly-expanding industry, securing precedent-setting results for our clients. As a result, numerous cases have garnered national publicity and are now routinely recognized in the legal community as standards by which certain managed care issues are decided.

Our managed care trial lawyers are thoroughly versed in every aspect of the law affecting managed care companies and ERISA plan administrators—It’s what we do every day. Highlights of our representative matters include a US Supreme Court win involving ERISA complete preemption and a high-profile First Amendment case victory involving defamation allegations against a managed care company.

Representing clients at the trial and appellate court levels, our lawyers have wide experience in defending clients, from those sued by individual plaintiffs to clients in putative class actions where plaintiffs seek millions of dollars in damages. Areas of our counsel include trials involving the following:

  • Commercial Provider Disputes and Litigation
    • Contract implementation disputes
    • Fraudulent coding, billing and adjudication practices
    • Out-of-network claims
    • Prompt pay statutory penalties
  • ERISA, Medicare and Affordable Care Act Benefits
    • Breach of fiduciary duty claims – members and sponsors
    • Class action lawsuits
    • Coverage and benefit disputes
    • Plan terms and coverage requirements
  • Emergency Care Statutes
    • Regulatory implementation and requirements
    • Prudent layperson and coverage standards
    • Usual-and-customary reimbursement standards and data
  • Affirmative Litigation
    • Fraudulent coding, billing and adjudication practices
    • RICO and related actions
    • Antitrust

Our Approach

Our practical approach to representing managed care companies fosters a collaborative relationship with our clients, delivering high-value services for predictable fees. In addition, we provide an array of pricing alternatives to meet our clients’ budgetary needs and leverage cutting-edge technology solutions to handle legal matters in the most innovative and efficient ways. The result is a formidable and strategic representation of managed care companies, focused on achieving the best results while prioritizing our clients’ business objectives.

Representative Cases

  • ERISA Complete Preemption (US Supreme Court)—Aetna Health Inc. v. Davila, 542 U.S. 200 (2004). Capping a decade of litigation, the US Supreme Court unanimously held that participants’ state law claims alleging injuries arising from Aetna’s interference with physician-recommended treatment were completely preempted by ERISA.
  • Prompt Pay Claims/Texas Supreme Court—Christus v. Aetna, Inc., 397 S.W.3d 651 (Tex. 2013). In a case of first impression, the Texas Supreme Court unanimously ruled in favor of a managed care company, holding that it was not liable under the Texas Prompt Pay law for claims for benefits which were unpaid after the failure of an intermediary delegated entity.
  • First Amendment/Defamation LawsuitTMJ Implants, Inc. v. Aetna, Inc., 405 F. Supp. 2d 1242 (D. Colo. 2005),aff'd, 498 F.3d 1175 (10th Cir. 2007). The firm successfully represented a managed care company in a lawsuit brought by a manufacturer and marketer of medical devices alleging defamation and commercial disparagement over the client’s clinical policy bulletin. The case was dismissed on First Amendment grounds in the Federal District Court of Colorado. This ruling was affirmed by the Tenth Circuit.
  • Provider Contract Claims—Mem’l Hosp. at Gulfport v. Aetna Health Mgmt., Inc., No. 1:04CV709-LG-RHW (S.D. Miss. 2007). The firm defended a managed care company against a hospital’s claims for breach of a provider agreement, bad faith, and mutual and unilateral mistake, with alleged damages of $1.6 million. After the summary dismissal of all but the mutual mistake claims, the remaining claim was tried before a jury, which rendered a take-nothing verdict in favor of the managed care company.
  • ERISA Plan Benefits—High v. E-Systems Inc. Long Term Disability Income & Death Benefit Plan, 459 F.3d 573 (5th Cir. 2006). The Fifth Circuit affirmed summary judgment in favor of the ERISA administrators in an opinion often cited for its ERISA standard of review principles.
  • Defense Jury Verdict in Libel Case—Khalil v. Aetna Life Ins. Co., No. H-03-5874 (S.D. Tex. 2005). The firm defended a managed care company in a jury trial in federal court brought by a Houston surgeon alleging that the managed care company had libeled him.A directed verdict was obtained after the completion of the cross-examination of the plaintiff.
  • Dispute with Former Customer—Administaff, Inc. v. Aetna Life Ins. Co., No. H-01-3802 (S.D. Tex. 2003). After a nine-day jury trial, the jury rejected all of a former customer’s claims for at least $380 million in goodwill and other tort damages, ultimately resulting in settlement for a portion of the rate increase which formed the basis of the remaining contract claim.
  • Lanham Act/Class Action Certification Denial—Ford v. NYLCare Health Plans of the Gulf Coast, Inc., 190 F.R.D. 422 (S.D. Tex. 1999),aff'd, 301 F.3d 329 (5th Cir. 2002). In a putative class action, the firm represented Aetna in defeating plaintiff’s motion for class certification of a national class of all board-certified physicians who contended that Aetna's advertising to prospective HMO members forced board-certified physicians into unfavorable contracts. The Fifth Circuit affirmed the denial of class certification and affirmed summary judgment in favor of the firm’s client with respect to the physician’s Lanham Act claim challenging Aetna’s advertising to prospective HMO members.
  • Challenge to State Tort Legislation—Corporate Health Ins., Inc. v. Tex. Dep’t of Ins., 314 F.3d 784 (5th Cir. 2002);Corporate Health Ins., Inc. v. Tex. Dep’t of Ins., 200 F.3d 641 (5th Cir. 2000); Corporate Health Ins., Inc. v.  Dep’t of Ins., 215 F.3d 526 (5th Cir. 2000); Corporate Health Ins., Inc. v. Tex. Dep’t of Ins., 12 F. Supp. 2d 597 (S.D. Tex. 1998). The firm represented managed care companies in five years of litigation challenging a Texas statute purporting to hold managed care entities liable for state tort damages in connection with plan administration. As a result, the liability provision of the statute was narrowly construed to encompass only vicarious liability claims, vastly reducing our clients’ risk of exposure under the statute.
  • Physician Deselection— Med. Ass’n v. Aetna Life Ins. Co., 80 F.3d 153 (5th Cir. 1996). Our argument on behalf of Aetna prevailed in a precedent-setting physician “deselection” case. We advocated that terminated physicians had no private cause of action under Texas law to enforce PPO rules, and lacked standing to assert unfair competition claims against Aetna. The Fifth Circuit affirmed the trial court’s dismissal of the case.