Two groups of medical care providers sued Aetna, seeking reimbursement for a medical procedure known as manipulations under anesthesia (“MUAs”). Plaintiffs’ patients had assigned their rights to insurance benefits to the medical groups. The complaint alleged that Aetna “generally denied the MUA claims on the basis that they were an unproven service, experimental, investigational, not medically necessary, or not a covered benefit or covered service under the plan.”
The complaint asserted claims under ERISA §§ 502(a)(1)(B) and 502(a)(3), as well as claims for civil penalties under ERISA for failure to provide documents. The complaint also asserted a claim for reimbursement under a theory of equitable estoppel.
The complaint included three broad factual allegations: (1) that the specific terms of each insurance plan provided coverage for MUAs; (2) that MUAs qualify as “medically necessary” procedures because they are included in the American Medical Association’s Codebook of Reimbursable Procedures; and (3) that Aetna orally represented that the MUAs were within the scope of the patients’ insurance coverage.
Aetna filed a motion to dismiss the complaint for failure to state a claim. The district court granted Aetna’s motion to dismiss, and the Eleventh Circuit upheld the district court’s decision.
The court first considered plaintiffs’ allegation that MUAs were medically necessary, and thus were covered procedures, for each patient in question. Plaintiffs’ primary factual support for their complaint, the AMA Codebook, did not support an inference that the MUAs were medically necessary, because (1) the AMA Codebook expressly stated that the inclusion of a procedure in the book did not represent an endorsement or imply health insurance coverage, and (2) the only plausible inference from the inclusion of MUAs in the AMA Codebook was that MUAs are generally accepted procedures.
Further, the allegation that plaintiffs received pre-approval of the procedures did not shed light on the question of medical necessity. Because the plaintiffs provided no further support for their claim that each MUA was medically necessary, the court determined that the plaintiffs did not create a plausible inference that they were entitled to benefits.
The Eleventh Circuit also considered the issue of standing for the ERISA breach of fiduciary duty and civil penalties claims. The court observed that healthcare providers fall outside of the group of parties with standing to sue under an ERISA plan, although they may obtain derivative standing by securing an assignment of rights.
Noting that assignment agreements are narrowly interpreted, the court determined that the right to bring suit under 29 U.S.C. § 1132 cannot be assigned “by implication or by operation of law.” Instead, the assignment must be “express and knowing.”
Interpreting the language of the assignment agreements, the court determined that the assignments only included the right to receive benefits, and not the right to assert claims for breach of fiduciary duty or civil penalties. Therefore, the Eleventh Circuit held that the medical providers did not have standing to bring these claims.
Finally, the court considered the plaintiffs’ equitable estoppel theory. Although the Eleventh Circuit has recognized equitable estoppel as a remedy in addition to the remedies explicitly authorized under ERISA, it is available only to plaintiffs who can show (1) that the relevant provisions of the plan at issue are ambiguous, and (2) that the plan provider or administrator made representations that constitute an informal interpretation of the ambiguity.
The court held that the plan language did not support the plaintiffs’ assertion that the terms “medically necessary” and “covered service” were ambiguous. Therefore, the plaintiffs’ equitable estoppel claim also failed.
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