Electrostim, a provider of medical electrical stimulation services, sued Blue Cross for several reimbursement issues, as well as wrongful contract termination. The Fifth Circuit found that the district court improperly denied leave to amend on the key issue, noting that in Electrostim’s briefing: “Electrostim specifically drew the district court’s attention to . . . partially paid claims and argued that its lawsuit challenged not only the denial of claims, but also the rate at which claims were paid. As we have explained, ERISA does not preempt state-law claims based on an allegedly improper rate of payment in violation of a provider agreement. Therefore, Electrostim has demonstrated, both to the district court and to this court, that because Electrostim can amend its complaint to put at issue the rate at which BCBSTX paid the partially paid claims, amendment would not be futile.” Electrostim Medical Services, Inc. v. Health Care Service Corp., No. 13-20649 (June 16, 2015, unpublished).
At issue in North Cypress Medical Center Operating Co. v. Cigna Healthcare was a basic aspect of the structure of a “preferred provider” insurance program. Under the many policies at issue, “in-network” providers receive more reimbursement than “out-of-network” ones, as an incentive to seek treatment in-network. With respect to the portion of the bill as to which patients had responsibility, certain providers provided “prompt pay” discounts. Insurers disputed whether they were then still responsible for the entire billed amount, or should have their responsibility reduced by a corresponding discount. The Fifth Circuit found that the patients, and thus the providers to whom they assigned their claims, had standing to litigate about this situation (reversing a district court ruling to the contrary). It also found that ERISA preempted state law claims about these issues, that limitations applied (without tolling) to compulsory counterclaims by insurers that sought affirmative relief rather than recoupment, and affirmed the dismissal of RICO claims by the provider. The litigation seems likely to continue, and to produce more issues about complicated and significant ERISA and procedural points. No. 12-20695 (March 10, 2015).
Among several other holdings in Clayton v. ConocoPhillips Co., the Fifth Circuit agreed that state law claims about benefits due under a severance plan were preempted by ERISA, when “an ongoing administrative program” is necessary because of discretion in the plan about eligibility, and when the plan is not fairly characterized as “a one-time, lump-sum payment triggered by a single event.” No. 12-20102 (July 3, 2013).
After granting en banc review, and thus vacating the panel opinion in Access Mediquip v. United Healthcare, the en banc court has now reinstated the panel opinion and expressly overruled prior cases that were in tension with the panel’s analysis of ERISA preemption as to misrepresentation claims. No. 10-20868 (Oct. 5, 2012).
The Court will rehear en banc the case of Access Mediquip v. United Healthcare, decided by the panel earlier this year, which presents a sophisticated question about when ERISA preempts certain misrepresentation claims.
The Court wrote at some length in Access Mediquip v. United Healthcare to clarify earlier cases about preemption of state law tort claims by ERISA. Access claimed that United made representations about payment for certain medical devices for three insureds. The Court rejected a reading of Transitional Hospitals v. Blue Cross, 164 F.3d 952 (5th Cir. 1999), that would find preemption if an alleged misrepresentation dealt with the extent of coverage. Op. at 12-13. “The dispositive issue . . . is therefore whether Access’s state law claims are dependent on, and derived from the rights of [the three insureds] to recover benefits under the terms of their ERISA plans.” Op. at 13. Under that framework, the Court found that Access’s claims for misrepresentation were not preempted by Transitional, but its unjust enrichment and quantum meruit claims were. Op. at 18-19. The opinion synthesizes several prior cases in this complicated, technical area of preemption law.