Aesthetic & Reconst. Breast v. United Healthcare
Aesthetic & Reconst. Breast v. United Healthcare
Opinion of the Court
It is a common practice for doctors and other medical providers to seek authorization from a patient's insurance company before agreeing to provide expensive medical care. As often as not, the provider contacts the insurance company and receives what it understands to be a pre-authorization. But sometimes the insurance company ends up deciding not to pay for what the provider thought was pre-authorized. So the question becomes whether the medical provider may recover in court against the insurance company.
That's essentially the question now before me in this case.
BACKGROUND
The following facts as alleged by the plaintiff in the amended complaint are accepted as true for purposes of ruling on defendants' motion to dismiss. Doc. # 7. Plaintiff Aesthetic and Reconstructive Breast Center, LLC, is a medical practice located in Louisiana run by Dr. Alireza Sadeghi, who specializes in reconstructive breast surgery. Dr. Sadeghi performed a medically necessary mastectomy on a patient in March of 2016, and then performed a medically necessary follow-up surgery on the same patient in July of 2016.
*4The patient worked for defendant Jacobs Engineering Group Inc., which sponsored her employee health plan. According to the complaint, defendant United Healthcare Group, Inc. (UHG) acted as the claims administrator for the plan.
The parties do not dispute that the plan is governed by ERISA. The Center was an out-of-network provider under the patient's plan. Doc. # 12-1 at 87. Under the terms of the plan, the patient could not assign her benefits under the plan to her medical provider without UHG's consent, Doc. # 12-1 at 88, and it is uncontested that the patient did not assign her benefits to the Center. See Doc. # 22 at 1-2.
Although the plan did not require it of an out-of-network provider prior to treating a patient, see Doc. # 12-1 at 87, the Center contacted UHG to request prior authorization before each surgery at issue in this case. UHG authorized rendering surgery in each instance. The Center alleges that the authorization created an implied contract by defendants to pay the Center a reasonable amount for the Center's services, and in the alternative, that the authorization was a promise to pay the Center a fair and reasonable rate for its services. After the surgeries, the Center billed defendants for a total of $ 390,700, which the Center alleges to be a reasonable rate for the surgical services performed. Defendants paid none of the billed charges.
The Center has filed this federal diversity lawsuit against defendants alleging the following causes of action: breach of contract (Count 1), promissory estoppel (Count 2), account stated (Count 3), and fraudulent inducement (Count 4). Defendants now move to dismiss. Doc. # 11.
DISCUSSION
For purposes of a motion to dismiss for failure to state a claim, the Court must accept as true all factual matters alleged in a complaint, although a complaint may not survive unless the facts it recites are enough to state plausible grounds for relief. See, e.g., Ashcroft v. Iqbal ,
Claims against Jacobs
The amended complaint alleges that Jacobs was the patient's employer but does not allege any actions taken by Jacobs to agree to or induce the Center to perform surgery for the patient. In the absence of any allegations that it was Jacobs who had dealings with the Center or did anything other than employ the patient, I will grant Jacobs' motion to dismiss as to all of the Center's claims against it.
*5Claims against UHG
The Center's amended complaint names "United HealthCare Group, Inc." as a defendant and the entity that administered the patient's insurance plan. Doc. # 7 at 1, 3 (¶ 4). A company identifying itself as "UnitedHealth Group, Inc. s/h/a United Healthcare Group, Inc." (whom I will assume to be the same as the named defendant, UHG) has filed this motion to dismiss, and it argues that the Center has sued the wrong corporate party, because the actual plan administrator was UHG's corporate subsidiary, UnitedHealthcare Insurance Company. Doc. # 12 at 1-2 & n.1, 8, 9; Doc. # 12-2 at 2-3 (¶ 4). UHG has filed alongside its motion to dismiss an affidavit attesting to this corporate relationship, as well as a copy of its Jacobs Engineering Group plan. Doc. # 12-1; Doc. # 12-2.
The corporate identity and affiliations of UHG are questions of fact, and for purposes of evaluating a motion to dismiss the Court must accept as true for pleading purposes all of plaintiff's allegations subject to any documents that are referenced in or otherwise integral to the complaint. See Goel v. Bunge, Ltd. ,
Because I must draw factual inferences in the Center's favor at this stage of the proceedings, I therefore will allow the case to proceed at this time against UHG without prejudice to a motion for summary judgment on this basis at a future time. The Court encourages counsel to consult in good faith to determine whether they can simply agree on this issue of the proper defendant to be sued rather than expending the Court's and clients' resources on the litigation of an issue that should be readily ascertained from appropriate documentation.
Adequacy of fraud allegations
Under Federal Rule of Civil Procedure 9(b), a plaintiff alleging fraud "must state with particularity the circumstances constituting fraud," such that the plaintiff must "(1) specify the statements that the plaintiff contends were fraudulent, (2) identify the speaker, (3) state where and when the statements were made, and (4) explain why the statements were fraudulent." United States ex rel. Chorches v. Am. Med. Response, Inc. ,
*6or "that constitute strong circumstantial evidence of conscious misbehavior or recklessness." Lerner v. Fleet Bank, N.A. ,
The only statement that the Center contends was fraudulent was the generalized "authorization" it alleges defendants made to the Center. At the same time, the Center fails to disaggregate defendants as speakers-let alone identify who provided the authorization with any greater degree of particularity. Nor has the Center identified any facts to support a fraudulent motive underlying defendants' inducement of the Center's services without pay, as opposed to nonpayment for some other reason, nor any facts to support a mental state of conscious misbehavior or recklessness. Doc. # 7 at 8-9 (¶¶ 47-53). I will therefore dismiss the fraudulent inducement claim as inadequately pleaded under Rule 9(b) of the Federal Rules of Civil Procedure.
ERISA preemption
UHG contends that ERISA preempts all of the Center's remaining claims. Doc. # 12 at 17. To begin with, it's helpful to clarify that "preempted by ERISA" can mean two different things. ERISA has two preemption provisions, located at Sections 502 and 514 of the Act. See
But because this lawsuit began in federal court, UHG is asserting the second form of ERISA preemption: "express" preemption under § 514(a) of the Act. See Doc. # 22 at 9. Save for some statutory exceptions that are not relevant here, a defendant may assert § 514 defensively to preempt (and defeat) any state law claims that "relate" to an ERISA plan.
As UHG sees it, then, the Center's claims should of course be preempted: § 514 applies to any state claim relating to an ERISA plan, is meant to be construed broadly, and the Center would not have contacted UHG for a pre-authorization absent the provisions of the patient's ERISA plan. And as UHG correctly points out in its briefing, see Doc. # 12 at 18, the Supreme Court has held that § 514 can preempt "common law causes of action" that are "based on the improper processing of a claim for benefits under an employee benefit plan," Pilot Life Ins. Co. v. Dedeaux ,
If only it were so simple. Since Pilot Life , the Supreme Court has made clear that when approaching the question of § 514 preemption, courts "must go beyond the unhelpful text and frustrating difficulty of defining ['relate' under § 514(a) ], and look instead to the objectives of the ERISA statute as a guide to the scope of the state law that Congress understood would survive." N.Y. State Conference of Blue Cross & Blue Shield Plans v. Travelers Ins. Co. ,
The Second Circuit has also recognized that how § 514 interacts with common law claims is a more nuanced question than a literal reading of the text would imply. In Paneccasio v. Unisource Worldwide, Inc. ,
Similarly, in Stevenson v. Bank of New York Co., Inc. ,
In line with this framework, at least two courts in this Circuit have dismissed doctors' common law claims against insurers who refuse to pay for medical procedures as preempted by § 514. See, e.g., *8Neurological Surgery, P.C. v. Siemens Corp. ,
The Second Circuit has not squarely addressed this distinction under § 514 of ERISA. It has, however, considered the problem under § 502. In Montefiore Medical Center v. Teamsters Local 272 ,
The Second Circuit has since held that the question shakes out differently when the patient does not validly assign her benefits to a non-network medical provider. In McCulloch Orthopaedic Surgical Services, PLLC v. Aetna Inc. ,
McCulloch , of course, is not directly on point. The court dealt with § 502 of ERISA rather than § 514, only considered a single claim for promissory estoppel, and addressed a question of how much an insurer would pay rather than if the insurer would pay at all. Although I am concerned that doing so may open the door to new litigation over a fairly common phenomenon "as anti-assignment clauses have become an increasingly prominent feature of health insurance contracts," Am. Orthopedic & Sports Medicine v. Indep. Blue Cross Blue Shield ,
Second, the McCulloch court's reasoning casts light on other principles of § 514 preemption. Third-party providers are not among the list of "core ERISA entities" such as beneficiaries described in Stevenson ,
Finally, McCulloch 's rule is consistent with the result reached by several other circuits that have indeed considered whether and how § 514 preempts state law claims by third party medical providers whom have not been assigned a patient's right to ERISA plan benefits but who alleged they were assured of payment by the insurer. In the Fifth Circuit, for example, "[a] defendant pleading preemption under [§ 514] must prove that '(1) the state law claims address an area of exclusive federal concern, such as the right to receive benefits under the terms of an ERISA plan; and (2) the claims directly affect the relationships among traditional ERISA entities-the employer, the plan and its fiduciaries, and the participants and beneficiaries.' " Access Mediquip L.L.C. v. UnitedHealthcare Ins. Co. ,
Other circuits have generally followed the Fifth Circuit's lead. See, e.g., Hospice of Metro Denver, Inc. v. Grp. Health Ins. of Okla., Inc. ,
While I am therefore persuaded that there is some room for a third-party medical provider to assert state law claims against an insurer when it has not been validly assigned its patient's benefits, I still must assess which-if any-of the Center's claims are preempted.
To begin with, I will dismiss the Center's contract claim as preempted by § 514. A contract claim requires proof of consideration as an element. See, e.g., Gianetti v. Norwalk Hosp. ,
The situation here is similar. UHG's supposed benefit, in the Center's view, is the ability to fulfill its obligations under the patient's plan through the Center's services, rather than to do so from elsewhere. Determining the merits of the Center's claim therefore would require a look to and reliance on the actual coverage terms of UHG's plan.
This result is consistent with the Second Circuit's framework for analyzing § 514 preemption of common law claims. Of course, it remains true that the Center is not an entity capable of suing under ERISA, and so does not satisfy the first prong of the Davila test. Yet because the Center seeks to bring a claim that derives from what a plan beneficiary-in this case, the patient-would be entitled to under the plan, the Center's claim still seeks to "rectify a wrongful denial of benefits" under the plan and does not arise from any independent duty existing between it and UHG. See Paneccasio ,
As with the contract claim, I will also dismiss the Center's claims for account stated. An account stated claim arises when a creditor delivers a debtor a statement of the debtor's account with canceled checks for the charges, and the debtor then retains for an unreasonable time the statement without disputing those charges. See Credit One, LLC v. Head ,
On the other hand, I will not dismiss the Center's claim for promissory estoppel against UHG. I reach this conclusion for substantially the same reasons as did the courts in McCulloch and Access Mediquip . The Center claims that UHG's authorization for the surgeries Dr. Sadeghi performed constituted a promise to pay him a reasonable amount for those services. As the court in McCulloch held, that alleged promise of reasonable payment is distinct from any obligations that UHG might have had under the plan to the patient. See
In short, I conclude that all of the Center's quasi-contract claims against UHG are preempted by § 514 except for the Center's claim for promissory estoppel.
Adequacy of promissory estoppel allegations
A plaintiff claiming promissory estoppel under Connecticut state law must prove (1) that the defendant did or said something intended to induce another party to believe that certain facts existed and to act on that belief, (2) that the plaintiff changed its position based on those facts, and (3) that doing so incurred some injury. See McKinstry v. Sheriden Woods Health Care Ctr., Inc. ,
UHG argues that the Center has failed to allege the existence of any clear and definite promise that it would be reasonably compensated, and that an authorization to perform the surgeries could not constitute that promise. Doc. # 12 at 13-14; Doc. # 22 at 6-7. I do not agree. When a provider wants to know whether it can reasonably expect reimbursement for caring for a patient, " 'it is a customary practice to communicate with the plan agents to verify eligibility and coverage,' " and "an ERISA plan can avoid liability under [State-law claims based on misrepresentations] by taking care that it does not mislead providers regarding what they can expect to be paid if they render services for the plan's insureds." Access Mediquip ,
Although UHG complains that the Center should have described aspects of the interaction between the Center and UHG with greater particularity, a claim for promissory estoppel is not one for "fraud or mistake" that is subject to the heightened pleading standards of Rule 9(b). Because the Center plausibly alleges that it received an authorization from UHG, that this authorization was a promise to receive reasonable payment for its services, and that the Center then relied on the promise to its detriment, I conclude that the Center has adequately stated a claim for promissory estoppel against UHG. See Doc. # 7 at 7 (¶¶ 38-41). I will allow the promissory estoppel claim against UHG to proceed at this time.
Defendants' motion to supplement the record
While this motion was pending, defendants moved to supplement the record and have the Court consider two pre-authorization letters that United claims to have sent to the Center for the surgeries. Doc. # 28 (motion); Docs. # 29-1; # 29-2 (letters). These letters are similar to the pre-authorization letter entered into the record with the consent of the plaintiff in the Theunissen case that is also before me. See Docs. # 48; # 48-1 to Taylor Theunissen, M.D., LLC v. United HealthCare Group, Inc. , 18cv606 (D. Conn. 2018).
Unlike in Theunissen , plaintiff does not consent to my consideration of the letters, and I will not consider them here. As I noted above, the Court may consider documents that are "integral" to the complaint *12when the complaint "relies heavily upon its terms and effect." Goel ,
Here, by contrast, the Center has alleged only contacting United and receiving authorization, but has not alleged that its communications with United were in writing or limited to writing. See Doc. # 7 at 4-5 (¶¶ 20, 24). Accordingly, I cannot conclude that the Center's complaint relies so heavily on any pre-authorization letters that it rises or falls on them, and so the letters are not so integral that I may consider them in evaluating the motion to dismiss. See Comprehensive Spine Care, P.A. v. Oxford Health Ins., Inc. ,
CONCLUSION
For the reasons set forth above, defendants' motion to dismiss (Doc. # 11) is GRANTED IN PART and DENIED IN PART. The claim for promissory estoppel against UHG may proceed. All other claims are DISMISSED. Defendants' motion to supplement the record (Doc. # 28) is DENIED.
It is so ordered.
The question is also presented in a similar case before me for which I am issuing today a separate ruling on the defendants' motion to dismiss. See Taylor Theunissen, M.D., LLC v. United HealthCare Group, Inc. , 18cv606 (D. Conn. 2019) (Order Granting Motions to Dismiss).
Although the complaint also names numerous "Jane Doe" and "ABC Corporation" defendants, I will dismiss any claims against such defendants for lack of any factual allegations about them.
The Center has not properly alleged facts to show that Jacobs was UHG's agent. An agency relationship in Connecticut requires particular elements including "(1) a manifestation by the principal that the agent will act for him; (2) acceptance by the agent of the undertaking; and (3) an understanding between the parties that the principal will be in control of the undertaking."Nat'l Pub. Co., Inc. v. Hartford Fire Ins. Co. ,
The "reference" prong of the Court's framework is less important in this case, because it deals with state laws "where the existence of ERISA plans is essential to the law's operation," Gobeille ,
Reference
- Full Case Name
- AESTHETIC AND RECONSTRUCTIVE BREAST CENTER, LLC v. UNITED HEALTHCARE GROUP, INC.
- Cited By
- 20 cases
- Status
- Published