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N.D. Ga.: Out-of-network Emergency Services and suits filed under ERISA

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  • N.D. Ga.: Out-of-network Emergency Services and suits filed under ERISA

    In a recent case from the Northern District of Georgia, a rural hospital filed suit against Blue Cross for ERISA benefits and breach of contract. In the years leading up to the suit, Blue Cross had historically paid the majority of the hospitals claims with few exception. After a potential agreement to bring the hospital "in-network" fell through, the hospital alleged that Blue Cross began refusing to pay claims as retaliation and issued refund demands for past payments.

    The Plaintiff also alleges that Blue Cross has issued refund demands to the Plaintiff for past payments made to it, sent notices to patients Blue Cross had already paid claiming it had overpaid them and demanding a refund, and consistently refused to pay, or underpaid, claims for services incurred by Blue Cross members at the Plaintiff’s facility.
    According to the Plaintiff, Blue Cross’s conduct has forced it to bill patients directly, which requires the Plaintiff to expend significant resources, and which often leaves the Plaintiff unsuccessful in obtaining this payment. On September 21, 2017, the Plaintiff filed this action. In its Complaint, the Plaintiff asserts claims for ERISA benefits pursuant to 29 U.S.C. § 1132(a)(1)(b), breach of contract, quantum meruit, money had and received, and violation of the Affordable Care Act. Blue Cross now moves to dismiss.
    With respect to the ERISA claims, the court found:

    [T]he Plaintiff’s Complaint does not satisfy these pleading requirements. The Complaint, which only describes “employee welfare benefit plans” under ERISA and other plans “to which ERISA does not apply,” fails to establish the ERISA plans under which it sues. It does not provide surrounding circumstances at all from which a reasonable person could “ascertain the intended benefits, a class of beneficiaries, the source of financing, and procedures for receiving benefits” under the plans at issue. Instead, the Plaintiff merely provides a vague reference to ERISA and non-ERISA plans in general. It also fails to distinguish between patients who were covered by ERISA plans and the patients who were covered by non-ERISA plans, which is a “crucial distinction.” The Complaint has provided Blue Cross no notice as to what claims the Plaintiff is bringing suit under, what ERISA and non-ERISA plans cover those claims, or how the Defendants have breached the terms of those plans. The Complaint provides almost no information at all detailing the claims and health plans at issue. This does not provide Blue Cross with the type of notice that allows it to respond to the allegations of the Complaint. Therefore, the Plaintiff fails to satisfy the pleading requirements for ERISA claims. The Plaintiff responds that it has adequately described the plans at issue in this case, and that requiring a plan-by-plan analysis would undermine judicial economy. The Plaintiff cites multiple cases for this proposition, and argues that a complaint need only generally describe plans consisting of ERISA plans and non-ERISA plans. However, in each of the cases cited by the Plaintiff, the complaint provides a specific number of ERISA and non-ERISA claims under which the plaintiffs sue, and also provides a list attached to the complaint providing details of these claims. Thus, the defendants in those cases could ascertain the plans and claims at issue. In contrast, the Complaint in this action only references ERISA and non-ERISA plans generally, with no other identifying information that allows the Defendants to identify any of the claims, plans, and terms of those plans underlying the Plaintiff’s allegations.
    Ultimately, the court granted the Defendant's Motion to Dismiss. The opinion is attached below.
    Attached Files
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