Court sides with Aetna in lawsuits over prescription drug coverage
Judges agreed with the plaintiffs' argument over who should pay for medications, but it did not apply retroactively, thus denying her relief.
The U.S. Court of Appeals for the Second Circuit on Friday ruled in favor of Aetna Life Insurance Company in a trio of cases involving health insurance coverage, upholding rulings from judges in the Southern District of New York.
The appeal, captioned Jacqueline Fisher v. Aetna Life Insurance, involves Aetna coverage provided to the law firm Dunnegan & Scileppi in 2014 and 2015. Fisher is the wife of Dunnegan & Scileppi attorney William Dunnegan, who acted as lead counsel in the case.
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Aetna was represented by Earl B. Austin III of Baker Botts in the appeal.
Fisher first sued Aetna in January 2015, asserting two claims for damages under the Employee Retirement Income Security Act of 1974. She argued that the document governing her 2014 health insurance coverage did not include Aetna’s “Choose Generic” provision, which was included in a document transmitted to her at a later date, and therefore Aetna should have covered her purchases of a brand-name prescription drug.
The panel, which included Circuit Judges Rosemary Pooler and Guido Calabresi and U.S. District Judge Edward R. Korman of the Eastern District of New York, who was sitting by designation, affirmed the district court’s ruling that Fisher was on notice regarding the later document, which was sent on Feb. 19.
“We agree with the district court that the terms of the February 19 Document were obvious and were called to D&S’s attention. Therefore, Fisher, through D&S, was on inquiry notice of the terms of the February 19 Document and the February 19 Document governs the contract of insurance between the parties,” the panel found.
The panel also considered Fisher’s argument that she needed only to reach the individual out-of-pocket limit under the terms of her insurance plan, rather than the family limit.
Because the text of the Affordable Care Act does not resolve that issue, the panel turned to regulations from the U.S. Department of Health and Human Services, finding that a rule aligned with Fisher’s side of the argument does exist, but it did not apply retroactively to the years involved in the lawsuit.
The panel also sided with other district court judgments against Fisher, finding that she was not entitled to a judgment for her copay differential, totaling $64.32, because Aetna’s decision was not arbitrary or capricious, in accordance with the standard set out under ERISA.
Aetna sent Fisher checks for $64.32 on three occasions, the panel noted, but she declined to cash them.
“Put simply, there is no reason to upend Aetna’s administrative decision to provide Fisher with the relief that she requested,” the panel found. “Although Fisher would like to receive a judgment granting her the exact relief that Aetna has already thrice attempted to provide, Fisher is not entitled to such a judgment.”
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