Encompass Office Solutions, Inc. v. La. Health Serv. & Indem. Co.
Opinion of the Court
Encompass Office Solutions, Inc. provided equipment and staffing for doctors to perform surgery in their own offices. Doctors and patients took to this service; insurers did not. Blue Cross and Blue Shield of Louisiana (BCBSLA) began denying Encompass's claims for in-office surgery support. BCBSLA instead paid a "Global Fee" to the doctor who performed the surgery, as compensation for all related services.
Encompass sued BCBSLA for ERISA violations, breach of contract, defamation, and tortious interference with business relations. BCBSLA largely prevailed at trial. But the district court granted a new trial because of error in the jury charge. At the second trial, Encompass won on all claims and obtained a judgment in its favor. On appeal BCBSLA says that the new trial should never have been granted, that no reasonable jury could have answered the contra non valentem (discovery rule) issue in favor of Encompass, and that BCBSLA did not abuse its discretion in denying Encompass's claims.
We AFFIRM the judgment of the district court.
I. BACKGROUND
A. Factual
Encompass provided the equipment, drugs, supplies, and nursing staff necessary for a doctor to perform outpatient surgery in his own office, rather than in a hospital or ambulatory surgical center (ASC). This was a novel arrangement-at the time, neither Texas nor Louisiana licensed such mobile providers of ambulatory surgical care.
Generally, when a doctor performs surgery at a hospital or ASC, an insurer like BCBSLA receives three claims: one from the doctor for doing the actual surgery; one from the anesthesiologist, if used; and one from the hospital or ASC for services provided to assist the doctor. When a doctor performs surgery in his office, however, there is no facility claim because there is no separate facility. Instead, BCBSLA pays doctors a Global Fee for these in-office surgeries. The Global Fee is greater than the fee paid to doctors for performing surgery at a hospital or ASC and is intended to compensate for all overhead costs of an in-office procedure.
When Encompass entered the market, it expanded doctors' ability to perform in-office surgeries. Encompass sought compensation from insurers by filing separate claims for its services. At all relevant times, Encompass was an out-of-network service provider for BCBSLA members.
*271Because of this, Encompass obtained an assignment of benefits from each of its BCBSLA-insured patients. BCBSLA paid Encompass's claims for several months after Encompass entered the Louisiana market.
But in June 2010, BCBSLA received a tip that Encompass was submitting claims for services it had not provided. On investigation, BCBSLA found that Encompass was submitting claims, and being paid, for the same in-office surgeries as the performing doctors. BCBSLA's billing system would normally reject "duplicate" claims for surgery at a doctor's office. But it had been processing Encompass's claims because they used a code modifier. Encompass was using the "TC Modifier," which stands for "technical component" and covers the equipment, staff, and services necessary for surgery.
BCBSLA began denying Encompass's claims. BCBSLA also learned that other insurance companies were doing the same. In August 2010, BCBSLA Vice President Dawn Cantrell sent a letter to in-network providers directing them not to use Encompass's services. Because this letter is the basis for Encompass's defamation and tortious interference claims, we quote it at length:
Encompass is not eligible to participate in the BlueCross networks and is considered an out-of-network provider. Please do not use Encompass for services provided to BlueCross or [HMO Louisiana, Inc.] members since the facility fees charged by Encompass are not covered, even when they are billed by a network physician. Encompass would have to be a Louisiana licensed [Department of Health and Hospitals]-approved ambulatory surgery facility in order to be eligible for payment of these facility charges.
You should also accept your contracted allowable charge for any eligible in-office surgeries you normally perform to be counted as payment in full and not allow Encompass to submit claims to Blue Cross. Please ensure your Blue Cross patients are able to receive network benefits for the services they receive from you by using participating providers.
If we find that any network physician is repeatedly using Encompass to deliver facility and procedure services that are not eligible for benefits and our members are being billed for these facility charges, the network physician will be subject to termination from the Blue Cross networks.
Encompass obtained a copy of the Cantrell Letter and gave it to counsel. Encompass sought clarification from BCBSLA by calling Cantrell three times and leaving voicemail messages. It received no response. In October 2010, BCBSLA Audit Consultant Alan Lofton sent Encompass a separate letter demanding repayment of nearly $ 110,000 in paid claims. A few months later, Encompass sued.
B. Procedural
Encompass initially sued BCBSLA for payment on services provided to BCBSLA insureds.
In response, BCBSLA pleaded that under its policy a non-facility provider must seek payment from the site-of-service owner, usually the doctor who orders the services, and that Encompass knew this.
*272BCBSLA explained that for surgeries in a "non-facility setting," the doctor's (and any other professional's) reimbursement is all-inclusive. In other words, BCBSLA pleaded its Global Fee policy.
In February 2013, Encompass deposed Cantrell and Lofton. Cantrell and Lofton testified they were not aware of a BCBSLA policy or benefit plan that said Encompass's services were not covered. And they were similarly unaware of a policy or plan permitting BCBSLA to terminate a physician for partnering with Encompass. This led Encompass to believe that the Cantrell Letter contained false statements. Because the Cantrell Letter damaged Encompass's Louisiana business, Encompass in April 2013 amended its complaint to add claims for defamation and tortious interference with business relations.
Both parties moved for summary judgment. The district court at first granted summary judgment to BCBSLA on Encompass's defamation and tortious interference claims because it held they were barred by Louisiana's one-year prescriptive period.
Trial arrived. Encompass tried its tort claims and non-ERISA contract claims to a jury, and its ERISA claims to the district court. The jury found no liability on the contract claims, and found that Encompass was not entitled to the benefit of contra non valentem on the tort claims. Because it resolved the prescription issue in BCBSLA's favor, the jury did not reach the merits of Encompass's tort claims.
Encompass moved for a new trial based on error in the jury charge, and the district court granted the motion. It held that the jury charge had imposed an incorrect liability standard for the non-ERISA contract claims. The original charge for these claims required the jury to find that BCBSLA "capriciously and arbitrarily" denied Encompass's claims for benefits. But it should only have required them to find the elements for Louisiana breach of contract. And, citing the potential for confusion, the court held that Encompass's tort claims must also be retried: "A finding that no breach occurred would reasonably cause the jury to find that no tort liability existed because the breach of contract claim underpins the basis for the tort claims." The district court did not rule on Encompass's ERISA claims at this stage.
At the second trial the jury found for Encompass on both its contract and tort claims, including finding that contra non valentem suspended prescription. The district court also found for Encompass on its ERISA claims. BCBSLA renewed its motion for judgment as a matter of law, moved for reconsideration, and moved for a new trial-all of which the district court denied. The district court entered judgment for Encompass, and BCBSLA appealed.
*273II. JURISDICTION AND STANDARDS OF REVIEW
A. Jurisdiction
The district court had jurisdiction based on complete diversity,
B. Standards of Review
1. Grant of a New Trial
"We review the district court's grant or denial of a new trial for abuse of discretion."
2. Judgment as a Matter of Law
"We review de novo the district court's denial of a motion for judgment as a matter of law, applying the same standards as the district court."
"We review all the evidence in the record in the light most favorable to the nonmoving party and draw all reasonable inferences in favor of the nonmoving party; we do not make credibility determinations or weigh the evidence."
3. ERISA § 502(a)(1)(B) Claims
"On appeal from a bench trial, this court review[s] the factual findings of the trial court for clear error and conclusions of law de novo ," applying the same standard as the district court.
III. DISCUSSION
A. District Court's Grant of a New Trial
In the first trial, the court instructed the jury that BCBSLA was liable on Encompass's non-ERISA claims if it had arbitrarily and capriciously denied claims for benefits:
The burden is on Encompass to prove that BCBS Louisiana had sufficient proof that payment on a claim was due and that the claim was capriciously and arbitrarily denied by BCBS Louisiana. An insurer is arbitrary and capricious when it does not act in a reasonable manner based on the facts known at the time of the decision.
In its motion for a new trial, Encompass successfully argued that this charge had erroneously imported the arbitrary-and-capricious standard and should, instead, have simply stated the Louisiana elements of contract.
1. New Trial on the Contract Claims
BCBSLA contends that the original charge was correct, and the second trial should never have happened. It says that the Louisiana Prompt Payment Statute,
All claims arising under the terms of health and accident contracts issued in this state, except as provided in Subsection B of this Section, shall be paid not more than thirty days from the date upon which written notice and proof of claim, in the form required by the terms of the policy, are furnished to the insurer unless just and reasonable grounds, such as would put a reasonable and prudent businessman on his guard, exist. ... Failure to comply with the provisions of this Section shall subject the insurer to a penalty ... together with attorney fees to be determined by the court.17
Although the words "arbitrary and capricious" do not appear in this section, Louisiana courts have adopted that standard for insurer liability.
BCBSLA also contends that Encompass itself invoked the Prompt Payment Statute for its non-ERISA contract claims. Besides contract damages, Encompass's operative complaint demanded attorney's fees, costs, and "statutory penalties under Texas and Louisiana law requiring the prompt payment of claims by insurance carriers." And in its submission for the joint pretrial order, Encompass listed "[w]hether BCBSLA abused its discretion by denying Encompass's claims" as a contested legal issue.
Neither of these theories can rehabilitate the first jury charge. Louisiana contract law governs Encompass's claims for benefits under non-ERISA plans because, although it is true that the Prompt Payment Statute applies to all Louisiana health insurance contracts, "[u]nder Louisiana law, the cause of action under [ § 22:1821 ] is separate and distinct from the cause of action for the breach of the insurance contract."
BCBSLA has another independent argument. It contends that the first jury charge was correct because the insurance plans, by their terms, granted BCBSLA discretion in choosing whether to allow or deny a claim. And in analogous contexts, "abuse of discretion" and "arbitrary and capricious" are legally equivalent.
This theory is not quite correct. BCBSLA argues that the first jury charge properly included an interpretation of the contracts. But the district court rejected this argument when it granted a new trial, holding in effect that the interpretation was not supported by Louisiana law.
In short, charging the jury with an incorrect standard of liability supports granting a new trial.
2. New Trial on the Tort Claims
The district court held that Encompass's tort claims should also be retried because they were related to the mischarged contract claims. In the district court's view, breach of the contracts was a basis of the tort claims. BCBSLA disputes this. It contends that the jury could not possibly have been confused by overlap of tort and contract issues because it never reached the merits of the tort claims. Indeed, the jury answered "no" to whether Encompass could invoke contra non valentem to toll prescription for the tort claims, preventing it from reaching the tort merits questions on the verdict form.
Under Federal Rule of Civil Procedure 59(a), the district court may "grant a new trial on all or some of the issues." "[P]artial new trials should not be resorted to unless it appears that the issue to be retried is so distinct and separable from the others that a trial of it alone may be had without injustice."
Under this standard, the district court did not abuse its discretion by granting a new trial on the tort claims. Whether Encompass's claims for benefits should have been paid was a common issue between the contract and tort claims-it affects the tort claims because it affects the truth or falsity of the Cantrell letter.
B. Judgment as a Matter of Law on Encompass's Tort Claims-Prescription and Contra Non Valentem
BCBSLA says that the district court should have granted its renewed motion for judgment as a matter of law based on prescription. It is undisputed that the applicable prescriptive period for Encompass's tort claims is one year, and that over a year passed between Encompass receiving the Cantrell letter and first claiming defamation and tortious interference. But the jury in the second trial found that prescription was suspended under the doctrine of contra non valentem .
Under Louisiana law, "[t]he defendant has the initial burden of proving that a tort claim has prescribed, but if the defendant shows that one year has passed between the tortious acts and the filing of the lawsuit, then the burden shifts to the plaintiff to prove an exception to prescription."
The Supreme Court of Louisiana has not evaluated contra non valentem for a defamation or false-statement claim. So "we must make an 'Erie guess' and determine as best we can what the highest court of the state would be most likely to decide."
BCBSLA maintains that contra non valentem does not apply as a matter of law. Encompass had a copy of the Cantrell Letter in 2010. The letter immediately caused Encompass to confer with counsel and seek clarification from BCBSLA. But Encompass waited until 2013 to allege tort claims. And in BCBSLA's view, Encompass is in a dilemma: Encompass's contract theory, which it was pursuing around the same time it received the Cantrell Letter, requires the letter to be wrong about coverage. But Encompass's contra non valentem theory only works if Encompass was ignorant of the letter's falsity.
Encompass contends that the Cantrell Letter falsified BCBSLA internal policies, which it could not discover until 2013 despite diligent inquiry. Although some statements in the letter were independently verifiable, Encompass says others were simultaneously false, damaging, and opaque to outsiders. Encompass argued that the letter misrepresented Encompass's "eligib[ility] to participate in the Blue Cross networks" and "eligib[ility] for benefit payment." Eligibility to be in the network, as distinct from present network status or plan coverage for a service, was a matter of BCBSLA policy. And according to Encompass, "eligib[ility]" for payment was too. Encompass says these statements damaged its business by discouraging doctors from working with it. Encompass also says its diligence to investigate the letter-calling Cantrell three times in 2010 and leaving messages without response-was reasonable under the circumstances.
We believe the Supreme Court of Louisiana would hold that contra non valentem was supported by the evidence here. The issue is close and we are mindful of the "especially deferential" standard of review for the jury verdict.
Louisiana intermediate appellate court decisions show that contra non valentem suspends prescription for defamation and other false-statement claims if a reasonably diligent plaintiff knows about the adverse statement but has not discovered it is false. In Quixx , for example, the insurer plaintiff received applications containing false statements, but prescription did not begin to run until it discovered facts inconsistent with those statements.
Cases setting a stricter diligence bar are distinguishable. In Rozas the plaintiff, a doctor, argued that contra non valentem suspended prescription as long as his former employer withheld a personnel file that defamed him as clinically incompetent.
And the appellate cases Greenblatt and Neyrey are distinguishable because the plaintiffs exercised no diligence at all.
Cases stating that consulting with counsel shows constructive knowledge of a claim are also distinguishable. These cases generally involved personal injuries where consulting counsel logically showed awareness of the cause of action.
Encompass can escape the posited tort-contract dilemma without contradiction. Encompass says that BCBSLA breached contracts by refusing to pay covered benefits and committed torts by spreading related statements that were false.
Encompass's status as a sophisticated corporation does not change this. The Supreme Court of Louisiana teaches that the proper "blueprint" to evaluate reasonable delay for contra non valentem is "looking to the record for evidence of facts within plaintiff's knowledge and then examining the reasonableness of plaintiff's inaction in light of those facts, considering plaintiff's education, intelligence and the nature of defendant's conduct."
Some evidence showed that in 2010 Encompass knew the Cantrell Letter stated unfavorable BCBSLA policies but not that those statements were false. Some evidence also showed that BCBSLA's conduct included misstating its policies and refusing to clarify things. And some evidence showed that Encompass was a corporation advised by counsel. So the jury had sufficient evidence to assess all the factors that Louisiana law considers.
C. Encompass's ERISA Claims
ERISA aims to promote the interests of plan participants and their beneficiaries and to "protect contractually defined benefits."
*281As a result, § 502(a)(1)(B) permits a plan participant to sue to "recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan."
1. Anti-Assignment Provisions
BCBSLA says that, under the plans' anti-assignment provisions, Encompass lacked derivative standing to sue for benefits. The district court found that BCBSLA waived the anti-assignment provisions because it made payments to, and communicated with, Encompass on at least some claims. BCBSLA's only direct challenge to this conclusion is that Encompass did not offer a jury charge on waiver. To the extent BCBSLA argues that waiver could only have been found by the jury, we disagree. It is well known that ERISA claims are the statutory cousins of equitable actions and so are tried to the court.
2. Contractual Limitations Periods
BCBSLA also contends that the plans' 15-month limitations provisions bar some of Encompass's claims.
*282As a result, we do not disturb the district court's conclusion that the contractual limitations provisions are unenforceable.
3. Abuse of Discretion
We now review the merits of Encompass's ERISA claims. To determine whether an administrator abused its discretion in construing a plan's terms, we analyze its plan interpretation in two steps.
In the second step-deciding whether BCBSLA abused its discretion-the court considers "(1) the internal consistency of the plan under the administrator's interpretation, (2) any relevant regulations formulated by the appropriate administrative agencies, and (3) the factual background of the determination and any inferences of lack of good faith."
Here, the district court only addressed the second step-whether BCBSLA abused its discretion. We take the same approach.
BCBSLA paid doctors a Global Fee for all services related to surgeries performed at their offices. The Global Fee compensated a doctor for both his professional services and the use of his facility. But when surgery was done at a hospital or ASC, BCBSLA made separate payments to those providers to compensate for use of their facilities and services. In BCBSLA's *283view, Encompass is distinguishable from hospitals and ASCs because it is only a service provider, not a physical facility. And for surgery at a doctor's office, BCBSLA's fee already included compensation for both his professional services and a facility. Thus, according to BCBSLA, any other payment would be duplicative.
This approach is not internally consistent. BCBSLA admits that the plans cover services like Encompass's, but cites no plan language authorizing it to limit payment based on who provided the service.
As for the other two abuse-of-discretion factors, we first note that the factual background of BCBSLA's decision shows equivocation over whether to do business with Encompass, rather than a clear understanding that its claims were improper.
In sum, BCBSLA abused its discretion by arbitrarily denying Encompass's claims for covered services, as shown by its inconsistent treatment of similar providers.
IV. CONCLUSION
We AFFIRM the judgment of the district court.
Encompass's original complaint named only BlueCross BlueShield of Texas. The second amended complaint added BCBSLA and a host of BlueCross entities from other states.
As the district court explained, "[t]he Louisiana Civil Code uses the term ... 'liberative prescription' for statutes of limitation." Encompass Office Sols., Inc. v. La. Health Serv. & Indem. Co. , No. 3:11-CV-1471-P,
"Contra non valentem non currit praescriptio means that prescription does not run against a person who could not bring his suit." Wells v. Zadeck ,
Gutierrez v. Excel Corp. ,
Scott v. Monsanto Co. ,
Gutierrez ,
Abraham v. Alpha Chi Omega ,
Fed R. Civ. P. 50(a).
Homoki v. Conversion Servs., Inc. ,
OneBeacon Ins. Co. v. T. Wade Welch & Assocs. ,
Homoki ,
Abraham ,
Conn. Gen. Life Ins. Co. v. Humble Surgical Hosp., L.L.C. ,
Singletary v. United Parcel Serv., Inc. ,
Stewart v. Calcasieu Par. Sch. Bd. ,
Cf., e.g. , Pumphrey v. City of New Orleans ,
Hymel v. HMO of La., Inc. ,
See Aero Int'l, Inc. v. U.S. Fire Ins. Co. ,
See Anderson v. Cytec Indus., Inc. ,
See Hymel ,
See Cook Indus., Inc. v. Cmty. Grain, Inc. ,
See Pinkerton v. Spellings ,
See, e.g. , Aero ,
The court responded by identifying this sentence in the jury charge: "An insurer is arbitrary and capricious when it does not act in a reasonable manner based on the facts known at the time of the decision."
Anderson v. Siemens Corp. ,
Colonial Leasing ,
See Anderson ,
See Colonial Leasing ,
Terrebonne Par.Sch. Bd. v. Columbia Gulf Transmission Co. ,
Marin v. Exxon Mobil Corp. ,
Id. at 246 (quoting Renfroe v. State ex rel. Dep't of Transp. & Dev. ,
Terrebonne Par. ,
Abraham ,
Nat'l Council on Comp. Ins. v. Quixx Temp. Servs., Inc. ,
Simmons v. Templeton ,
Rozas v. Dep't of Health & Human Res. ,
Greenblatt v. Payne ,
Safford v. PaineWebber, Inc. ,
See Med. Review Panel Proceeding of Williams v. Lewis ,
See, e.g. , Simmons ,
Cf. Marshall Invs. Corp. v. R.P. Carbone Co. , No. 05-6486,
See, e.g. , Safford ,
Wells ,
See Homoki ,
See
N. Cypress Med. Ctr. Operating Co., Ltd. v. Cigna Healthcare (NCMC) ,
Calamia v. Spivey ,
See Fed. R. Civ. P. 39(a) ("The trial on all issues so demanded must be by jury unless: ... the court, on motion or on its own, finds that on some or all of those issues there is no federal right to a jury trial."); Austin v. Shalala ,
BCBSLA maintains that its October 4, 2010 demand letter placed Encompass on notice that its claims would be denied. Encompass waited over 15 months from this date to file suit. So BCBSLA contends that all Encompass claims submitted before October 4, 2010 are barred by limitations.
Heimeshoff v. Hartford Life & Accident Ins. Co. ,
See Santana-Diaz v. Metro. Life Ins. Co. ,
Humble Surgical Hosp. ,
Humble Surgical Hosp. ,
NCMC ,
Id. at 195 (alteration in original) (quoting Crowell v. Shell Oil Co.,
Humble Surgical Hosp. ,
McCorkle v. Metro. Life Ins. Co. ,
Wildbur v. ARCO Chem. Co. ,
Bellaire Gen. Hosp. v. Blue Cross Blue Shield of Mich. ,
See, e.g. , McCorkle ,
See Vega ,
See Lain v. UNUM Life Ins. Co. of Am. ,
See Wildbur ,
See
Dissenting Opinion
I respectfully dissent from the majority's conclusion upholding the contra non valentem exception to prescription for this sophisticated medical services company that was fully represented by counsel from virtually the moment it reviewed the Cantrell letter. This is not an issue on which deference to the jury verdict is required. The facts are plain and undisputed. Encompass and its counsel were on more than "inquiry notice" from the terms of the letter-they had actual knowledge of the alleged false and defamatory statements in that letter. Encompass's counsel explained the company's position succinctly in closing argument. According to him, the letter contained three "false statements": Encompass was not "eligible to participate" in the Blue Cross networks; facility fees charged by Encompass "are not covered" even when billed by the network physician; and Encompass had to be state-licensed to be "eligible" for reimbursement.
Encompass sued BlueCross BlueShield of Louisiana ("BCBSLA") not long thereafter, following its related suit against Texas Blue Cross, on a theory of breach of contract arising from this letter and *284BCBSLA's failure to pay Encompass for its services on behalf of insureds. Encompass knew from the outset it was "eligible," and it knew there was no "state license" requirement. As for the third falsehood, it knew quite enough, that BCBSLA was not reimbursing it for in-office surgical assistance because of the claimed scope of insurance coverage. Whether coverage denial was because of the policy language or internal company policies, or both, or neither, is precisely the kind of nuance a lawyer should investigate. But it took Encompass three years after filing suit to add this intimately related claim for falsehood and defamation.
"Louisiana courts have held in regard to contra non valentem that a cause of action becomes reasonably knowable to a plaintiff at the time legal counsel is sought." Derrick v. Yamaha Power Sports of New Orleans ,
Importantly, misleading conduct by a defendant does not lift the burden of diligence from a sophisticated plaintiff who knows or reasonably should know that further inquiry would reveal a cause of action. Marin v. Exxon Mobil Corp. ,
Although my colleagues have diligently reviewed Louisiana law on contra non valentem, I respectfully disagree with their application of those cases to these facts. I would reverse the judgment for extracontractual and punitive damages.
Reference
- Full Case Name
- ENCOMPASS OFFICE SOLUTIONS, INCORPORATED, Plaintiff-Appellee, v. LOUISIANA HEALTH SERVICE & INDEMNITY COMPANY, Doing Business as BlueCross BlueShield of Louisiana. Defendant-Appellant.
- Cited By
- 25 cases
- Status
- Published