Rush Prudential HMO, Inc. v. Debra C. Moran, et al.

Rush Prudential HMO, Inc. (Rush) (defendant) provided medical services under employer welfare benefit plans covered by ERISA, agreeing to pay for "medically necessary" services, including from off-list specialists if approved by the patient's primary doctor and Rush's medical director. Debra Moran (plaintiff), covered under Rush's plan, was denied approval for a recommended shoulder surgery with an unaffiliated specialist on grounds it wasn't medically necessary. Moran invoked Illinois's HMO Act to demand an independent medical review, which Rush initially resisted; after removal fights between state and federal court, an independent physician found the surgery necessary, but Rush's medical director still denied it, and Moran sought reimbursement for the surgery she ultimately had. Rush argued Illinois's independent-review requirement was completely preempted by ERISA; the district court agreed, but the court of appeals reversed, and the Supreme Court granted certiorari.