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Anti-assignment Provision and The Scope of an Assignment: 11 Cir.

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  • Anti-assignment Provision and The Scope of an Assignment: 11 Cir.

    In a recent case from the 11th Circuit, the court wrestles with the applicability of an Anti-assignment provision, as well as the scope of the attempt to assign benefit. After having her patient execute an assignment, the Plaintiff submitted claims seeking payment to the Defendant, which the Defendant paid only in part. The Plaintiff then appealed internally twice, requesting a copy of the summary plan description during the second appeal. The Defendant denied both, and did not respond to the request for plan documents. Following the denial of the second appeal:

    Several years after United Healthcare denied Dr. Griffin’s appeal, she obtained a second assignment from E.V. The assignment authorized Dr. Griffin to request plan documents on E.V.’s behalf. It also assigned to Dr. Griffin E.V’s right to “pursue claims for benefits, statutory penalties, breach of fiduciary duty, [and] any ERISA claim matter.” Doc. 14 at 29. The assignment stated that it was effective retroactive to 2012 when Dr. Griffin treated E.V.
    After obtaining the second assignment, Dr. Griffin sued United Healthcare and Viking in state court. She brought four claims under ERISA for: (1) failure to pay plan benefits, (2) breach of fiduciary duty, (3) failure to provide plan documents, and (4) breach of co-fiduciary duties. Dr. Griffin claimed that the defendants were liable because they had underpaid the claims and also failed to provide the plan documents that Dr. Griffin requested when she submitted the second-level appeal.
    United Healthcare and Viking removed the action to federal court and then filed motions to dismiss. The district court granted the motions, concluding that Dr. Griffin’s claim for failure to pay plan benefits was barred by the Plan’s anti-assignment provision. The district court assumed that Dr. Griffin’s other claims, which related to the failure to provide plan documents, were not barred by the Plan’s anti-assignment clause. The court nonetheless concluded that Dr. Griffin could not sue for these claims because E.V.’s original assignment did not transfer to Dr. Griffin the right to sue for these non-payment-related claims. And the court explained that the second assignment, which purported to assign E.V.’s right to sue for claims related to the failure to provide plan documents, could not be applied retroactively against third parties such as United Healthcare and Viking. The district court dismissed the case. This appeal followed.
    The court reviewed the matter de novo and found:

    In this case, E.V.’s original assignment purported to transfer to Dr. Griffin the right to payment of benefits. We have recognized that when a patient assigns to a provider the right to payment for medical benefits, she also conveys the right to file an action under § 502(a) of ERISA for unpaid benefits. See Conn. State Dental Ass’n v. Anthem Health Plans, Inc., 591 F.3d 1337, 1352-53 (11th Cir. 2009). Thus, if enforceable, the assignment transferred to Dr. Griffin the right to bring a cause of action under ERISA for unpaid benefits. But the Plan’s anti-assignment provision prohibited E.V. from assigning her benefits to Dr. Griffin and therefore barred Dr. Griffin’s claim seeking to recover unpaid benefits under § 502(a) of ERISA.
    Dr. Griffin argues that United Healthcare and Viking cannot rely on the anti-assignment provision because they failed to notify her of the provision after she asked whether the Plan contained such a term. Liberally construed, Dr. Griffin’s argument is that United Healthcare and Viking are either equitably estopped from relying on the anti-assignment provision in the Plan or have waived it. We disagree.
    Under ERISA, equitable estoppel applies only when “the plaintiff can show that (1) the relevant provisions of the plan at issue are ambiguous, and (2) the plan provider or administrator has made representations to the plaintiff that constitute an informal interpretation of the ambiguity.” Jones v. Am. Gen. Life & Accident Ins. Co., 370 F.3d 1065, 1069 (11th Cir. 2004). Because the anti-assignment provision is unambiguous, equitable estoppel cannot apply here.
    We have “left open the question of whether waiver principles might apply under the federal common law in the ERISA context.” Witt v. Metro. Life Ins. Co., 772 F.3d 1269, 1279 (11th Cir. 2014). Even if we assume that waiver could apply in the ERISA context, Dr. Griffin has failed to plead sufficient facts to show that United Healthcare and Viking waived the anti-assignment provision. “[W]aiver is the voluntary, intentional relinquishment of a known right.” Id. (internal quotation marks omitted). We have explained that waiver may be express or implied, but to find implied waiver, “the acts, conduct, or circumstances relied upon to show waiver must make out a clear case.” Id. (internal quotation marks omitted).
    We conclude that Dr. Griffin has failed to make out a clear case that waiver applies here. Her allegation that United Healthcare and Viking failed to respond to her inquiry about the existence of an anti-assignment provision is insufficient to establish a “clear case” that they intentionally and voluntarily relinquished their rights under the anti-assignment provision.
    The full opinion is attached below.
    Attached Files