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Wednesday, April 27, 2011

The ability of an “in-network” health care provider to sue an ERISA health benefit plan for breach of contract in state court depends on the nature of its claim

The ability of an “in-network” health care provider to sue an ERISA health benefit plan for breach of contract in state court depends on the nature of its claim
Montefiore Med. Ctr. v. Teamsters Local 272, 10-1451-cv, USCA 2nd Circuit

The question presented in this appeal: May a healthcare provider’s breach of contract and quasi-contract claims against an ERISA health benefit plan were completely preempted by federal law under the two-prong test for preemption established in Aetna Health Inc. v. Davila, 542 U.S. 200?

The Davila two-prong test to determine whether a claim falls “within the scope” of §502(a)(1)(B). provides that claims are completely preempted by ERISA if they are brought:
a. by “an individual [who] at some point in time, could have brought his claim under ERISA § 502(a)(1)(B),”; and

b. under circumstances in which “there is no other independent legal duty that is implicated by a defendant’s actions.”

The Circuit Court noted that the test is conjunctive; i.e., a state-law cause of action is preempted only if both prongs of the test are satisfied.
The Circuit Court of Appeals ruled that:

1. An “in-network” health care provider may receive a valid assignment of rights from an ERISA plan beneficiary pursuant to ERISA §502(a)(1)(B)*;

2. Where a provider’s claim involves the right to payment and not simply theamount or execution of payment, i.e.,  where the claim principally implicates coverage and benefit determinations as set forth by the terms of the ERISA benefit plan, and not simply the contractually correct payment amount or the proper execution of the monetary transfer—that claim constitutes a colorable claim for benefits pursuant to ERISA §502(a)(1)(B).

In this instance, said the court, at least some of Montefiore's claims for reimbursement are completely preempted by federal law. However, the Circuit Court noted, the remaining state-law claims are properly subject to the exercise of the District Court’s supplemental jurisdiction.

The decision is posted on the Internet at:

* 1 Section 502(a)(1)(B) provides, in relevant part: A civil action may be brought -- (1) by a participant or beneficiary -- (B) to recover benefits due to him [or her] under the terms of his [or her] plan, to enforce his [or her] rights under the terms of the plan, or to clarify his [or her] rights to future benefits under the terms of the plan.

Handbooks focusing on State and Municipal Public Personnel Law continue to be available for purchase via the links provided below:

The Discipline Book at http://thedisciplinebook.blogspot.com/

A Reasonable Penalty Under The Circumstances at http://nypplarchives.blogspot.com

The Disability Benefits E-book: at http://section207.blogspot.com/

Layoff, Preferred Lists at http://nylayoff.blogspot.com/

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