Grand Traverse Band of Ottawa & Chippewa Indians v. Blue Cross & Blue Shield of Mich.
Grand Traverse Band of Ottawa & Chippewa Indians v. Blue Cross & Blue Shield of Mich.
Opinion of the Court
JUDITH E. LEVY, United States District Judge *710In its earlier stages, this case was about claims brought under the Employee Retirement Income Security Act ("ERISA"),
I. Background
The Court provided a complete factual background of the underlying claims in its previous opinion and order granting in part and denying in part defendant's motion to dismiss, which it reincorporates fully here. (Dkt. 99 at 2-6.) For clarity, the Court summarizes the background and notes new developments in the case's procedural history.
The Tribe is federally-recognized. The Tribe maintains a self-funded employee welfare plan, the Plan, which covers three groups of participants: members of the Tribe who are employed by the Tribe (Group #01010); members of the Tribe who are not employed by the Tribe (Group #01020); and employees of the Tribe who are not members of the Tribe (#48571). BCBSM has been the Plan administrator since 2000. (Dkt. 90-2 at 3.)
In 2007, new federal regulations went into effect which provided that "[a]ll Medicare-participating hospitals ... must accept no more than the rates of payment under the methodology described in this section as payment in full for all terms and services authorized by [Indian Health Service], Tribal, and urban Indian organization entities," and even if the parties had negotiated different rates, tribes would "pay the lesser of" the amount determined by the methodology and the negotiated amount.
Plaintiffs allege that they asked BCBSM to ensure that they were receiving MLR for the Tribe member groups, Groups #01019 and #01020. (Dkt. 90 at 14). BCBSM claimed that "it could not adjust its entire system to calculate MLR on those claims eligible for MLR discounts," but could provide a rate that would be close to MLR by providing a discount for plaintiffs' claims for services at the Munson Medical Center to Group #01020, the non-employee Tribe members. (Id. at 15.) This led the parties to enter into the Facility *711Claims Process Agreement ("FCPA") with Munson Medical Center, effective on March 1, 2009. (Dkt. 90 at 6; Dkt. 90-4.) However, in 2012, plaintiffs obtained a third-party audit and discovered that they were "not paying anything 'close to MLR' on claims." (Dkt. 90 at 16.) They state that they "did not discover the full extent of BCBSM's" conduct until 2013. (E.g. ,
Plaintiffs filed their first complaint on April 1, 2014. (Dkt. 1.) On January 24, 2019, plaintiffs were permitted to file an amended complaint, alleging breach of fiduciary duty under ERISA, violations of the HCFCA, breach of contract and the covenant of good faith and fair dealing in the alternative, breach of common law fiduciary duty, fraud and misrepresentation, and silent fraud. (Dkt. 90.) BCBSM filed a motion to dismiss those claims (Dkt. 94), which the Court granted in part and denied in part. (Dkt. 99.) The Court dismissed all claims except for the breach of contract claim, noting that the parties agreed that the breach of common law fiduciary duty and HCFCA claims were preempted by ERISA. (Id. at 22, 25.) Plaintiffs filed a motion for reconsideration (Dkt. 101) and a motion to file a second amended complaint (Dkt. 102), and both were denied. (Dkt. 107.)
In August 2018, the Sixth Circuit held that the Saginaw Chippewa Indian Tribe of Michigan's Welfare Benefit Plan was not an ERISA plan when it covered non-employee Tribe members. Saginaw Chippewa Indian Tribe of Mich. v. Blue Cross Blue Shield of Mich. ,
II. Legal Standard
When deciding a motion to dismiss under Federal Rule of Procedure 12(b)(6), the Court must "construe the complaint in the light most favorable to the plaintiff and accept all allegations as true." Keys v. Humana, Inc.,
III. Analysis
For the reasons set forth below, plaintiffs raise claims under the HCFCA and *712for breach of common law fiduciary duty, but only state a claim as to the HCFCA. Plaintiffs have statutory standing under the HCFCA. However, their breach of fiduciary duty claim, although cognizable, is barred by the statute of limitations.
A. Health Care False Claims Act
In its motion, defendant argues that plaintiffs lack statutory standing under the HCFCA. (Dkt. 117 at 11.) It is undisputed that plaintiffs must meet the definition of a "health care insurer" to have statutory standing under the HCFCA.
Statutory standing is a matter of statutory interpretation. Miller v. Allstate Ins. Co.,
"[C]lear and unambiguous" statutory language is the best evidence of legislative intent. Perkovic ,
When the text of the statute is ambiguous because two equally reasonable readings are possible, courts "should give effect to the interpretation that more faithfully advances the legislative purpose behind the statute." People v. Adair ,
Statutory interpretation begins with the text of the statute. The text at issue here is " 'health care insurer' means ... any legal entity which is self-insured and providing health care benefits to its employees. " § 752.1002(f) (emphasis added). "[P]roviding" is a form of "to provide," meaning "to supply or make available."
Defendant argues that a plain-text reading of "is ... providing" means that self-insured entities like plaintiffs are only health care insurers when or while they are providing benefits to their employees (see Dkt. 117 at 11-12; Dkt. 120 at 2-6),
In contrast, plaintiffs argue that the "providing" clause should be read as a threshold requirement, meaning that as long as plaintiffs are continuously supplying health care benefits to employees, they are health care insurers for all purposes under the HCFCA (Dkt. 119 at 12), and the Court agrees. This interpretation does not rewrite the statute in any way or change the grammatical function of any words. Moreover, this interpretation also gives meaningful force to every word and phrase. Once a self-insured entity offers health care benefits to employees continuously, it is a health care insurer. This reading avoids rendering the phrase "is ... providing" a restrictive, prepositional phrase when it is not written that way. Therefore, interpreting "providing" as a threshold requirement is the plain text definition.
Out of an abundance of caution, however, the Court considers the best-case scenario for defendant-that the plain text is ambiguous, and so it is necessary to consider the legislative purpose and other canons of construction. However, the legislative *714purpose and scheme and canon against absurdity demonstrate that "providing" is best interpreted as a threshold requirement.
First, the legislative purpose and scheme counsel in favor of reading "providing" as a threshold requirement. The preamble of the HCFCA declares a clear purpose: "to prohibit fraud in the obtaining of benefits or payments in connection with health care coverage and insurance" and "to provide for ... certain civil actions." Mich. Comp. Laws Ch. 752, Refs & Annos, amended by P.A. 1996, No. 226, § 1 (June 5, 1996); State ex rel. Gurganus v. CVS Caremark Corp., Nos. 29998, 299999,
Under defendant's reading, plaintiffs would receive no special protection or redress against healthcare-based fraud even though they offer health care benefits and insurance. Defendant offers no reasonable explanation, nor can the Court think of one, why the legislature would exclude tribes and their plans from the HCFCA's protection, or why health care fraud is less concerning when tribes are the insurer. Generally, entities self-insure as a matter of convenience, i.e. there is a large enough number of members to evenly distribute the costs of the policy. Employers are often self-insured because they have access to large, organized groups that permit them to offer group health insurance at a rate that is not prohibitively high. It also happens that tribes are similarly positioned with respect to their own members. The Court could not find another entity in Michigan other than employers and tribes that self-insure. It is doubtful that the Michigan Legislature would draft a statute that would grant a remedy to nearly all self-insured employers except the non-employee Tribe members of the twelve
Second, interpreting "providing" as a durational requirement would lead to absurd results because plaintiffs would be health care insurers as to employees, but not as to non-employees, even where plaintiffs are offering the same health care benefits. The Court cannot guess why the legislature would desire this outcome when both plans would be equally susceptible to fraud. The Court has rejected analogous statutory interpretation arguments when it would lead to inconsistent application of the statute without a persuasive justification. Zen Design Grp. Ltd. v. Scholastic, Inc. , No. 16-12936,
For these reasons, plaintiffs are health care insurers within the meaning of the HCFCA and have statutory standing. Therefore, they state a claim for which relief can be granted.
B. Common Law Breach of Fiduciary Duty
Defendant also argues that plaintiffs fail to state a claim for breach of common law *715fiduciary duty. Specifically, it argues that the statute of limitations bars the claim (Dkt. 117 at 13-14), and in its reply brief, defendant argues for the first time that the fiduciary duty claim is not cognizable under Michigan law. (Dkt. 120 at 8-9.) But defendant misconstrues Michigan law and the Court's previous rulings; plaintiff states a claim for which relief may be granted because its fiduciary duty claim is cognizable
i. Cognizability
In Michigan "a plaintiff '[may] not maintain an action in tort for nonperformance of a contract.' " DBI Invs., LLC v. Blavin ,
To determine "whether a [tort] action based on a contract ... may lie," courts apply the " 'separate and distinct' mode of analysis." Fultz v. Union-Commerce Assocs. ,
In fact, a separate and distinct analysis "generally does not necessarily involve reading the contract, noting the obligations required by it, and determining whether plaintiff's injury was contemplated by the contract." Id. at 169,
1. Fiduciary Relationship
For a fiduciary duty to exist, a fiduciary relationship must also exist. A fiduciary relationship may arise "when one person assumes control and responsibilities over another." Calhoun ,
Here, plaintiff pleads facts that, if proven true, show a fiduciary relationship exists under Michigan law, which defendants do not dispute. (Dkt. 117 at 13-14.) Plaintiffs allege that under the Administrative Services Contract ("ASC"), the parties entered a fiduciary relationship. (Dkt. 90 at 10.) Plaintiffs explain that as an administrator, defendant "was required to make decisions about whether to pay a health care claim from Plan funds, and how much to pay from Plan funds, with the Plaintiffs' bests interest in mind and in a manner that preserved Plan assets" and to do so "with the care, skill, prudence, and diligence of a prudent person." (Id. at 3.) Moreover, plaintiffs attach the ASC itself, which supports this interpretation of the relationship.
2. Separate and Distinct Analysis
A fiduciary duty existed that is separate and distinct from the FCPA. Loweke requires the Court to consider whether defendant has any duty at all to act for *717plaintiffs that exists separately and distinctly from the FCPA, and here, a legal duty does exist apart from the FCPA. Moreover, Loweke is clear-the focus is on whether any legal duty exists separately and distinctly from the contract, not whether the conduct is contemplated by the contract. Even if the FCPA did not exist, defendant would have a fiduciary duty to manage the Plan with plaintiffs' best interest in mind and to act as a reasonably prudent investor and not squander plan assets based on the ASC. Therefore, plaintiffs have stated a claim that is the separate and distinct from their contractual breach claim regarding the FCPA.
Defendant argues that the Court's previous ruling that the state fraud claims were barred is dispositive to the breach of common law fiduciary duty claim (Dkt. 120 at 7-8), but this argument is unpersuasive. Earlier, the Court held that plaintiffs' fraud claims that defendants made misrepresentations about MLR and failed to disclose when plaintiffs were not receiving MLR were not cognizable because "any obligation to provide rates close to MLR and any obligation to disclose such discrepancies ... arose from the existence of the FCPA." (Dkt. 99 at 24-25.) In other words, plaintiffs could not point to a duty separate and distinct from the FCPA that required defendant to deliver MLR and disclose when MLR were not delivered. But here, plaintiffs plead that defendant had an obligation to meet its fiduciary duty that did not arise from the FCPA.
ii. Statute of Limitations
Defendant also argues that this claim is untimely. Plaintiffs' claim that defendant breached its common law fiduciary duty is subject to a three-year statute of limitations.
Plaintiffs admit that in 2009, they had actual knowledge that defendant was violating its fiduciary duty. (Dkt. 119 at 116.) In 2000, the parties signed the ASC, establishing a fiduciary relationship. (Dkt. 90-2 at 15.) After the 2007 regulations went into effect, "BCBSM's fail[ed] to take advantage of MLR discounts ... [and this]
*718was a breach of BCBSM's fiduciary duties under ERISA" (Dkt. 90 at 4-5), and the parties do not dispute these duties are identical to common law fiduciary duties. Then plaintiffs learned in 2009 that they were not receiving MLR discounts, i.e. that defendant was violating its fiduciary duty under ERISA. Defendant's conduct at this point, whether it be characterized as not offering competitive rates, preserving plan assets, etc. or offering rates close to MLR, breached its common law fiduciary duties to prudently manage funds and act with plaintiffs' best interests in mind.
Plaintiffs raise two counterarguments. First, they argue that there is "a second type of 'wrong' by BCBSM," which is that defendant violated its common law fiduciary duties after the parties "entered into the FCPA in 2009 to specifically address BCBSM's past squandering of plan assets" and that it did not know of that breach of fiduciary duty until after the audit in 2012. (Dkt. 119 at 16, 18.) In other words, plaintiffs only maintain the breach of fiduciary duty claim from the point that the FCPA was signed and onward. (Id. at 7 n.2.) But plaintiffs cannot have it both ways. Plaintiffs have prevailed on the separate and distinct analysis and are therefore permitted to raise both a fiduciary duty and contractual breach claim. They cannot now conflate the separate duties by arguing the FCPA somehow reinvigorated the fiduciary duty or created a new fiduciary duty, in effect resetting the clock on the claim. The claim cannot be maintained after 2009 because plaintiffs knew of the breach in 2009-that defendant continued to breach its fiduciary duties and plaintiffs did not realize this until 2012 is not relevant to the question of when they first knew of the breach of fiduciary duty, as is the fact that plaintiffs sought to put additional pressure on defendant by entering the FCPA to impose specific contractual terms.
Second, plaintiffs argue that the statute of limitations should be tolled. They appear to raise two arguments: that defendant fraudulently concealed the claim by failing to disclose the second breach of fiduciary duty and by making an affirmative misrepresentation by entering the FCPA. There is no legal support for either argument.
First, plaintiffs argue that defendant failed to disclose a material fact, its breach of fiduciary duties after it signed the FCPA, which amounts to fraudulent concealment in Michigan. (Dkt. 119 at 19-21 (citing
Plaintiffs also argue that they had no reason to suspect defendant of a breach after the FCPA was signed because the FCPA was a specific representation that defendant would no longer squander plan assets (id. at 21), but this argument also fails. Again, plaintiffs already knew of the breach, and so the rule against fraudulent concealment of a claim does not apply. Yet even if the rule did apply, plaintiffs must plead that defendant intended to prevent the discovery of the claim. Roman Catholic Archbishop ,
In 2009, it appears that plaintiffs chose not to pursue legal action for defendant's breach of fiduciary duty, and instead gave defendant the benefit of the doubt and let it attempt to cure its deficient conduct. Shrewdly, plaintiffs entered into the FCPA and imposed more specific requirements upon the relationship to see if matters improved. And now, when it alleges that defendant failed to live up to the spirit of the parties' relationship, it will be able to pursue contractual relief. However, it will not be able to turn back the clock on the breach of fiduciary duty claim that it knew of in 2009. For these reasons, plaintiffs fail to state a claim for a breach of common law fiduciary duty.
IV. Conclusion
For the reasons set forth above, plaintiffs state a timely claim for relief on their HCFCA claim but not their common law breach of fiduciary duty claim. The HCFCA claim will continue with plaintiff's state law breach of contract claim against defendant based on the FCPA. (Dkt. 99 at 25.)
Accordingly, defendant's motion to dismiss (Dkt. 117) is GRANTED IN PART as to the HCFCA claim and DENIED IN PART as to the common law breach of fiduciary duty claim.
IT IS SO ORDERED.
Defendant filed a notice of supplemental authority regarding Saginaw Chippewa Indian Tribe of Michigan v. Blue Cross Blue Shield of Michigan , No. 16-cv-10317,
Provide , Merriam Webster's Dictionary, https://www.merriam-webster.com/dictionary/provide (last updated May 20, 2019).
Only self-insured legal entities that also offer benefits to non-employees are self-insured legal entities that can raise a claim under the HCFCA now. Cf. § 752.1002(f) (providing that insurance companies may also be health care insurers). As the parties agree, ERISA preempts the HCFCA, and as Saginaw recently clarified, ERISA only applies to employee-plans.
There are twelve federally recognized tribes in Michigan. Federally Recognized Tribes in Michigan, Mich. Dep't of Health & Hum. Servs., https://www.michigan.gov/mdhhs/0,5885,7-339-73971_7209-216627--,00.html (last visited May 20, 2019).
Arguments raised for the first time in a reply brief are considered waived. Scottsdale Ins. Co. v. Flowers ,
Federal and state courts disagree whether the separate and distinct principle applies to cases where the parties are in privity. See Hamilton v. Nochimson , No. 09-13366,
The court may consider such an attachment at the motion to dismiss stage if it is "referred to in the plaintiff's complaint" and is "central to her claim." Amini v. Oberlin Coll. ,
Although whether defendant violated its contractual obligations by failing to deliver MLR or violated its fiduciary duties by squandering plan assets, not prudently managing, etc., may seem like semantics because the underlying violative conduct is the same, the distinction is crucial. The separate and distinct principle focuses on whether there are distinct duties, and thus the Michigan Supreme Court contemplated that the same conduct could lead to more than one origin for liability. Indeed, the Michigan Supreme Court could decide to apply the doctrine of economic loss in all contracting contexts, but it has not done so to date. Galeana ,
A hypothetical scenario may clarify this point. Assume that the statute of limitations is not at issue and the breach of contract and fiduciary duty claims exist at the same time. Further assume that a rate close to MLR is between 5 and 5.5% and a competitive market rate is 6%. Defendant gives plaintiffs a rate of 7%. This conduct violates the FCPA that requires close to MLR and the common law fiduciary duties to act as a prudent investor and with the best interests of the beneficiary in mind, which here would at least require a competive market rate. Although the conduct is singular, it breaches two separate duties. See supra , p. 21 n.8.
Plaintiffs' counterarguments are similar to an equitable estoppel argument, which tolls the running of the statute of limitations, not its commencement as fraudulent concealment does. See West Am. Ins. Co. v. Meridian Mutual Ins. Co. ,
Reference
- Full Case Name
- The GRAND TRAVERSE BAND OF OTTAWA AND CHIPPEWA INDIANS, and Its Employee Welfare Plan v. BLUE CROSS AND BLUE SHIELD OF MICHIGAN
- Cited By
- 2 cases
- Status
- Published