W.A. Griffin v. Teamcare
W.A. Griffin v. Teamcare
Opinion
W.A. Griffin, M.D., is the assignee of her patient's health plan, TeamCare, which the Board of Trustees of Central States, Southeast and Southwest Areas Health and Welfare Fund (collectively Central States) administers and the Employee Retirement Income Security Act (ERISA),
I. BACKGROUND
We recite the facts as alleged in the complaint.
Allen v. GreatBanc Tr. Co.
,
Before receiving treatment, T.R. assigned to Dr. Griffin the rights under the plan to "pursue claims for benefits, statutory penalties, [and] breach of fiduciary duty ...." Dr. Griffin confirmed through a Central States representative that the plan would pay her for the treatment at the usual, reasonable, and customary rate, as section 11.09 of the plan document provides. * Dr. Griffin then treated T.R. and submitted a claim for $7,963, which she says is the applicable usual and customary rate, but Central States underpaid her by $5,014.
Dr. Griffin challenged the benefits determination. She wrote to Central States in February 2017, arguing that she received less than the usual, reasonable, and customary rate promised in section 11.09. She also asked for a copy of the summary plan description and the documents used to determine her payment, like rate tables and fee schedules.
Six months later, Central States responded. It explained that Data iSight, a third party, used "pricing methodology" to determine Dr. Griffin's fee. It advised her to negotiate with Data iSight before engaging in the two-step appeals process that the plan required her to complete before she could bring a civil suit. (Dr. Griffin missed a call from Data iSight about negotiating a settlement; Dr. Griffin returned the call and left a voicemail explaining that she "would not take any reductions on the amount owed," and Data iSight never called her back.) Central States also provided a copy of the summary plan description, but no fee schedules or tables.
According to Dr. Griffin, "At this point, [she] had exhausted appeals." She called the six-month delay before she heard back from Central States "unreasonable." "The appeals process is a fake process designed to waste time," she continued. "Heading straight to court sooner as opposed to later is the correct course of action."
Dr. Griffin sued Central States under ERISA, which authorizes plan participants or beneficiaries to sue for benefits due and equitable relief.
Dr. Griffin alleged that Central States did not pay her the proper rate for her services under section 11.09 of the plan (Count 1); breached its fiduciary duty by not adhering to the plan's terms (Count 2); and failed to produce, within 30 days, the requested summary plan description, Data iSight's fee schedules, or Central States's contract with Blue Cross Blue Shield (Count 3).
Central States moved to dismiss Dr. Griffin's complaint, and the district court granted the motion. The court determined that Dr. Griffin failed to state a claim for unpaid benefits because she did not identify a specific plan provision that covered the services provided, i.e., one that "confer[s] benefits," which the court said was required under
Clair v. Harris Tr. & Sav. Bank
,
II. ANALYSIS
We review the district court's judgment de novo.
Allen
,
Count 1: Damages for Unpaid Benefits,
Dr. Griffin challenges the district court's ruling that she did not state a claim for unpaid benefits. She argues that she adequately plead that the plan covered the medical treatment she provided T.R. and that she did not need to cite in her complaint a plan provision establishing coverage at the amount she billed.
We agree. "[P]laintiffs alleging claims under
Dr. Griffin likewise did not need to name a provision entitling her to greater reimbursement than what the plan paid. In its motion to dismiss, Central States properly understood that Dr. Griffin alleged that the plan "underpriced and underpaid her claim," but it argued that she had to point to a plan provision allowing her "greater payment." Dr. Griffin, however, alleged that Central States did not pay her the usual, reasonable, and customary rate, which is what she says she charged and what section 11.09 of the plan requires. To require her to be more specific is to turn notice pleading on its head. Indeed, as discussed later, Dr. Griffin did not have the information necessary to allege with more detail where the plan's calculation of the usual and customary rate went astray.
Last, Central States included in its brief an unsupported assertion that Dr. Griffin's failure to exhaust her administrative remedies warranted affirmance. Because it did not develop this argument, it is waived on appeal.
See
FED. R. APP. P. 28(a)(8), (b) ;
Kramer v. Banc of Am. Sec., LLC
,
Count 2: Breach of Fiduciary Duty,
Dr. Griffin next challenges the dismissal of her claim that Central States breached its fiduciary duty. But Dr. Griffin does not contest the district court's dismissal of her second claim as duplicative of the first. Equitable relief under section 1132(a)(3) is available only when Congress did not provide relief elsewhere.
Varity Corp. v. Howe
,
Count 3: Statutory Penalties,
Finally, Dr. Griffin argues that as T.R.'s assignee, she is a beneficiary of the plan, eligible for statutory penalties based on Central States's failure to provide the documents she requested within 30 days.
See
But in
Neuma, Inc. v. AMP, Inc.
, we remanded to the district court for a determination of whether penalties should be awarded to an assignee under section 1132(c)(1), thus assuming that assignees could seek penalties.
Bringing that suit (or an administrative appeal) requires access to information about the plan and its payment calculations-here, how Central States determined the usual, reasonable, and customary rate.
Mondry
,
Central States responds that even if Dr. Griffin is a beneficiary, she still did not state a claim for statutory damages because it sent her the summary plan description, and ERISA did not require it to furnish either Data iSight's fee schedules and rate tables or its contract with Blue Cross Blue Shield.
This argument is meritless. First, Central States did turn over the summary plan description and plan document-but five months after the 30-day deadline.
See
Second, Central States was also required to produce, as requested, Data iSight's fee schedules. The fee schedules, used to calculate Dr. Griffin's payment, are part of the "pricing methodology" that Central States cited in explaining Dr. Griffin's benefits, and thus they are the basis of its benefits determination.
See
Mondry
,
Finally, Dr. Griffin also requested a copy of the contract between Central States and Blue Cross Blue Shield, but she was never provided a copy of that contract. That contract governs the operation of the plan in that it defines the roles of the plan and claims administrators. Therefore, Central States was required to provide that document to her.
III. CONCLUSION
The district court's judgment dismissing Count 2 of the complaint is AFFIRMED. However, we VACATE the judgment regarding Counts 1 and 3 and REMAND those Counts for further proceedings consistent with this opinion.
Dr. Griffin did not attach the plan document to her complaint, but we may consider it because Central States included it in its motion to dismiss, Dr. Griffin referenced it in her complaint, and it is central to her claim.
See
Mueller v. Apple Leisure Corp.
,
Reference
- Full Case Name
- W. A. GRIFFIN, M.D., Plaintiff-Appellant, v. TEAMCARE, a Central States Health Plan, and Trustees of the Central States, Southeast and Southwest Areas Health and Welfare Fund, Defendants-Appellees.
- Cited By
- 32 cases
- Status
- Published