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Pennsylvania Chiropractic Association, New York Chiropractic Council, et al v. Blue Cross Blue Shield Association

January 23, 2011

PENNSYLVANIA CHIROPRACTIC ASSOCIATION, NEW YORK CHIROPRACTIC COUNCIL, ET AL., PLAINTIFFS,
v.
BLUE CROSS BLUE SHIELD ASSOCIATION, ET AL., DEFENDANTS.



The opinion of the court was delivered by: Matthew F. Kennelly, District Judge:

MEMORANDUM OPINION AND ORDER

The plaintiffs in this case are medical professionals, associations, and facilities, as well as Katherine Hopkins, an individual subscriber.*fn1 The defendants are Blue Cross and Blue Shield Association and individual Blue Cross and Blue Shield entities, including WellPoint, Inc. and Community Insurance Company d/b/a Anthem Ohio (Anthem Ohio). The plaintiffs other than Hopkins generally allege that defendants initially reimbursed them for services they provided to BCBS insureds and then sometime afterward would make a false or fraudulent determination that the payments had been in error and would demand repayment.

Hopkins claims that she received medical services at Miami Valley Hospital (MVH) for which her insurer, Anthem Ohio, paid. Two years later, however, Hopkins received a bill from MVH informing her that Anthem Ohio had recouped funds it had paid to the hospital, making her liable for the balance.

In plaintiffs' fourth amended complaint, Hopkins asserts claims under the Employee Retirement Income Security Act (ERISA) and for injunctive relief against WellPoint and Anthem Ohio, arguing that they used improper procedures in recouping funds from MVH. The Court previously dismissed Hopkins' claims for prospective equitable relief based on her admission that she is "no longer a participant or beneficiary in her former employer's health plan" and her statement that she would seek relief only "with regard to pre-existing repayment demands and recoupments, and defers to other Plaintiffs for an injunction applicable to Defendants' future misconduct." Order of April 27, 2011 (dkt. no. 486); see also April 28, 2011 Tr. at 7.

Anthem Ohio and WellPoint have moved for summary judgment on Hopkins' remaining claims. For the reasons stated below, the Court grants the motion.

Background

As of September 2007, Hopkins was insured through her employer, Queen City Reprographics, under an Anthem Ohio policy. The policy had an annual member deductible of $500 for in-network care and a co-payment requirement of twenty percent for most covered services. Hopkins left Queen City in 2008 and is no longer covered under Anthem Ohio's plan.

On September 9, 2007, Hopkins was taken by ambulance to MVH and was treated there. On October 12, 2007, Anthem Ohio made separate payments of $876.88 and $476.88 to MVH based on what it later claimed were duplicate claims by MVH for Hopkins' treatment. On July 30, 2008, an Anthem Ohio vendor sent a letter to MVH regarding Hopkins' treatment, entitled "Request for refund of overpayment," that requested "remittance in full" of $876.88. Def. Ex. I. The letter included two tables. The first stated in part:

Amount Due: $876.88

Reason: duplicate payment Patient Name: KATHERINE HOPKINS Date(s) of Service: September 09, 2007 Total Charges: $2,514.00 Total Paid: $876.88 Payee Name: MIAMI VALLEY HOSPITAL Id. The letter then indicated that the "calculations" underlying the request were based on the following information (reproduced in part):

Date of Charge Allowed Patient Benefit Services Liability

ACTUAL: 9/09/07 $2,514.00 $1,096.10 $219.22 $876.88 RECALCULATED: 9/09/07 $2,514.00 $1,096.10 $619.22 $476.88 Id. Anthem Ohio did not notify Hopkins that this letter had been sent.

On June 16, 2009, MVH paid $876.88 to defendants in response to the recoupment demand. On or around November 12, 2009, Hopkins received a letter from a collection agency stating that she owed a balance of $619.22 to MVH. Hopkins testified at her deposition that this was the first time she was notified that "Miami Valley Hospital had a balance due and owing from" her. Hopkins Dep. 85:23-86:2. She testified further that she contacted the collection agency and Anthem Ohio upon receipt of this letter to obtain information regarding what, if anything, she owed. She has provided letters she sent to MVH in November 2009 and to Anthem Ohio in January 2010 requesting documentation regarding her balance. Anthem Ohio responded with a notice indicating that it was "unable to process documents" because Hopkins had not provided her account identification number. Pl.'s Ex. 3.

Hopkins asserts two claims under ERISA. In count one, she seeks unpaid benefits and interest, repayment of any amounts wrongfully paid or withheld, and declaratory and injunctive relief enforcing the terms of the plan. She brings this claim under section 502(a)(1)(B) of ERISA, which states, "A civil action may be brought by a participant or beneficiary to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of ...


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