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Advanced Ambulatory Surgical Center, Inc. v. Cigna Healthcare of Illinois

United States District Court, N.D. Illinois, Eastern Division

September 30, 2014





Between December 2010 and November 2012, Plaintiff Advanced Ambulatory Surgical Center, Inc. ("AASC") rendered surgical services to various patients who were insured under health plans administered by Defendant Cigna Healthcare of Illinois ("Cigna"). Prior to performing these services, AASC contacted Cigna to verify each patient's coverage. In every case, Cigna assured AASC that all claims would be reimbursed in full. When AASC later billed Cigna, however, Cigna refused to pay on the basis that it believed AASC had engaged in "fee-forgiving, " a practice whereby certain out-of-network medical providers, in an effort to gain a competitive advantage over other providers, agree to overlook a patient's deductible or co-payment obligations and accept reimbursement under a plan as payment in full. Unsurprisingly, insurance companies disapprove of this practice because it eliminates any incentive for patients to choose in-network providers over pricier out-of-network providers. To discourage fee-forgiveness, many benefit plans, including those administered by Cigna, exclude coverage for any expenses that a plan member is not obligated to pay personally.

On September 5, 2013, AASC initiated this action in the Circuit Court of Cook County, seeking reimbursement for each of the outstanding claims that Cigna refuses to pay. In its Complaint, AASC denies that it engaged in fee-forgiving and asserts that Cigna determined incorrectly that it was entitled to withhold payment on that basis. The Complaint advances state-law claims for promissory estoppel, unjust enrichment, fraud, and violation of Section 155 of the Illinois Insurance Code, 215 Ill. Comp. Stat. 5/155. Cigna removed the action to this Court on grounds that (1) AASC's claims are preempted by the Employee Retirement Income Security Act, 29 U.S.C. § 1001 et seq. ("ERISA"), and (2) the Court has diversity jurisdiction under 28 U.S.C. § 1332. Cigna now seeks to dismiss the case in its entirety. It also asks that AASC's jury demand be stricken in the event that all claims are not dismissed. For the reasons stated herein, both Motions are granted in part and denied in part.


A. Motion to Dismiss

The outstanding health insurance claims at issue in this case relate to forty patients, twenty-six of whom are members of benefit plans that are governed by ERISA (the "ERISA Patients"). Cigna seeks to dismiss the Complaint as it relates to payments for those patients on the basis that AASC's state-law theories are preempted by ERISA. As for the claimed payments relating to the remaining fourteen patients who are not members of ERISA plans (the "Non-ERISA Patients"), Cigna has moved to dismiss those claims pursuant to Rule 12(b)(6) of the Federal Rules of Civil Procedure. (Actually, it is unclear whether or not one of those fourteen patients is a member of an ERISA or non-ERISA plan. Considering the lack of discovery in the case, however, the Court will afford AASC the benefit of the doubt and treat that patient as though his plan is not governed under the more stringent ERISA standard.) The Court evaluates each ground for dismissal in turn.

1. ERISA Preemption

Federal law preempts state-law claims in three circumstances:

(1) where federal law states explicitly that it overrides relevant state law ("express" preemption), (2) where federal law conflicts with state law to such an extent that "it would be impossible for a party to comply with both [state] and federal requirements or where [state] law stands as an obstacle to the accomplishment and execution of the full purposes and objectives of Congress" ("conflict" preemption), and (3) where federal law "so thoroughly occupies a legislative field as to make it reasonable to infer that Congress left no room for the states to act" ("field" or "complete" preemption). Hoagland v. Town of Clear Lake, Ind., 415 F.3d 693, 696 (7th Cir. 2005) (quotation marks and citations omitted). Cigna argues that AASC's claims in this case are preempted expressly, by virtue of ERISA's express preemption provision, 29 U.S.C. § 1144(a) ("ERISA § 514(a)"), and under the doctrine of complete preemption, through ERISA's comprehensive civil enforcement scheme, 29 U.S.C. § 1132(a) ("ERISA § 502(a)").

ERISA § 514(a) provides, with some exceptions not relevant to this case, that ERISA supersedes "any and all State laws insofar as they may now or hereafter relate to any employee benefit plan." 29 U.S.C. § 1144(a). A state law "relates to" a benefit plan "if it has a connection with or reference to such a plan." Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 47 (1987).

ERISA § 502(a) allows an ERISA plan participant or beneficiary to sue to recover benefits under the terms of the plan, enforce rights under the terms of the plan, or clarify rights to future benefits under the terms of the plan. 29 U.S.C. § 1132(a)(1)(B). The Supreme Court has held that state-law claims that fall within the scope of ERISA § 502(a) are completely preempted and, therefore, come within the original jurisdiction of the federal courts. Metropolitan Life Ins. Co. v. Taylor, 481 U.S. 58, 66 (1987). In assessing whether a particular state-law claim falls within the scope of Section 502(a), courts first must determine whether the plaintiff could have brought his claim under ERISA § 502(a) and, second, must examine whether the defendant's actions implicate a legal duty that is separate or independent from those created by ERISA. Aetna Health Inc. v. Davila, 542 U.S. 200, 209 (2004).

a. Unjust Enrichment Claim

AASC's unjust enrichment claim is premised on the allegation that Cigna "received substantial monetary benefit, in the form of premiums and/or fees" under the various healthcare plans at issue but refused to pay AASC because it believed that AASC had been engaged in fee-forgiving. Claims of this sort merely recast under state-law what otherwise would be a traditional challenge to an ERISA plan administrator's interpretation of the terms of a plan. Access Mediquip L.L.C. v. UnitedHealthcare Ins. Co., 662 F.3d 376, 386-87 (5th Cir. 2011). Allowing such claims to proceed unpreempted ...

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