United States District Court, S.D. Florida
ORDER GRANTING PLAINTIFF'S MOTION TO
L. ROSENBERG UNITED STATES DISTRICT JUDGE.
cause is before the Court on Plaintiff's Motion to
Remand. DE 3. Defendant has filed a response, DE 13, and
Plaintiff has filed a reply. DE 14. The Court has considered
these filings and is otherwise fully advised in the premises.
For the reasons that follow, the Motion is GRANTED.
Orthopaedic Care Specialists, P.L. is an emergency-medicine
group that staffs the emergency departments at St. Mary's
Medical Center and Children's Hospital. On February 12,
2019, Plaintiff provided emergency medical services to a
patient designated as R.B., who is a member of a health plan
administered by Defendant Aetna Life Insurance Company.
Plaintiff billed Defendant for reimbursement of its costs in
providing services to R.B., and Defendant issued a payment as
to some of the service, while declining to issue payment for
other services on the basis that they were not medically
necessary. The payments that Defendant did issue were below
Plaintiff's billed charges and below the fair market
value of the services rendered. Plaintiff has no contract
with Aetna and did not agree to accept discounted rates of
reimbursement from Aetna. Defendant sent Plaintiff an
Explanation of Benefits notice, which stated:
The member's plan provides benefits for covered expenses
at the reasonable charge for the service in the geographical
area where it is provided. In certain circumstances,
especially where the service is unusual or not often provided
in the geographical area, the reasonable charge may be
determined by considering other factors, including the
prevailing charge in other areas. You are not part of our
network and therefore we cannot prevent you from billing the
member for any balance. But if you do, we reserve the right
to challenge your bill.
filed the Complaint in state court on August 29, 2019,
alleging that Defendant's failure to pay Plaintiff the
lesser of the billed charges or the fair market value of the
services violated Sections 641.513(5) and
627.64194(4) of the Florida Statutes. These statutes
require reimbursement of emergency-medicine providers at the
lesser of the billed rate, market rate, or a mutually agreed
rate. The Complaint also alleges that Plaintiff and Defendant
had an implied-in-fact contract requiring Defendant to pay
Aetna the reasonable value of the medical services it
provided R.B. Plaintiff seeks compensatory damages,
declaratory relief, and attorney's fees.
removed the case on October 9, 2019, on the basis that
Plaintiff's claims are completely preempted by the
Employee Retirement Income Security Act of 1974
(“ERISA”), 29 U.S.C. § 1132(a) et
seq. Plaintiff filed its Motion to Remand on October 10,
2019, arguing that its claims were not preempted and
therefore that this Court lacks jurisdiction.
federal question must generally appear on the face of a
well-pleaded complaint to support jurisdiction under 28
U.S.C. § 1331. Metro. Life Ins. Co. v. Taylor,
481 U.S. 58, 63 (1987). “Complete preemption is a
narrow exception to the well-pleaded complaint rule and
exists where the preemptive force of a federal statute is so
extraordinary that it converts an ordinary state law claim
into a statutory federal claim.” Conn. State Dental
Ass'n v. Anthem Health Plans, Inc., 591 F.3d 1337,
1343 (11th Cir. 2009). Complete preemption is jurisdictional
rather than an affirmative defense, and when it applies, the
complaint may be removed to federal court. Id. at
1344. However, federal courts are courts of limited
jurisdiction, and uncertainties about jurisdiction are
resolved in favor of remand. Burns v. Windsor Ins.
Co., 31 F.3d 1092, 1095 (11th Cir. 1994).
Aetna Health Inc. v. Davila, the Supreme Court held
that ERISA completely preempts state-law causes of action
within the scope of its civil enforcement remedy. 542 U.S.
200, 209 (2004). Under the Davila two-part test,
complete preemption exists when (1) the plaintiff could have,
at some point, brought a claim under section 502(a) of ERISA,
and (2) no independent legal duty supports the
plaintiff's claim. Ehlen Floor Covering, Inc. v.
Lamb, 660 F.3d 1283, 1287 (11th Cir. 2011) (citing
Davila, 542 U.S. at 210). To establish the first
prong of the Davila test-whether the plaintiff could
have brought a claim under section 502(a)-an additional two
factors are required under Eleventh Circuit precedent. First,
the plaintiff's claims must “fall within the scope
of ERISA § 502(a), ” and second, Plaintiff must
have standing to sue. Ehlen Floor, 660 F.3d at 1287
(citing Conn. State Dental, 591 F.3d at 1350).
502(a), codified at 29 U.S.C. §1132(a), authorizes civil
actions “by a participant or beneficiary . . . to
recover benefits due to him under the terms of the plan, to
enforce his rights under the terms of the plan, or to clarify
his rights to future benefits under the terms of the
plan.” § 1132(a)(1)(B). For the reasons discussed
below, the Court concludes that Defendant has not
demonstrated that Plaintiff has standing to sue under ERISA.
Accordingly, ERISA does not completely preempt
Plaintiff's claims, irrespective of whether the claims
fall within the scope of ERISA section 502(a) and whether an
independent legal duty supports Plaintiff's claims.
are two categories of persons authorized to sue under section
502(a)(1)(B): “plan beneficiaries” and
“plan participants.” Phys. Multispecialty
Grp. V. Health Care Plan of Horton Homes, Inc., 371 F.3d
1291, 1294 (11th Cir. 2004). Generally, healthcare providers
are neither beneficiaries nor participants. Id.
However, providers can acquire derivative standing “by
obtaining a written assignment from a ‘beneficiary'
or ‘participant' of his right to payment of
benefits under an ERISA-governed plan.” Id.
(citing Hobbs v. Blue Cross Blue Shield of Ala., 276
F.3d 1236, 1241 (11th Cir. 2001)). Defendant has “the
burden of producing facts supporting the existence of federal
subject matter jurisdiction by a preponderance of the
evidence, ” and “[w]ithout proof of an
assignment, the derivative standing doctrine does not
apply.” Hobbs, 276 F.3d at 1242.
Plaintiff does not allege that it was assigned R.B.'s
benefits. Rather, Defendant seeks to prove that there was a
written assignment of benefits to Plaintiff by submitting (i)
a declaration by a paralegal employed by Defendant, and (ii)
a screenshot of Defendant's “Electronic Workflow
Management” system, showing the entry corresponding to
Plaintiff's claim for services rendered to R.B. DE 1-3.
The screenshot shows a digital text entry with the word
“ASSIGN” and the letter “A” next to
it. Id. at 283. The declaration states that
“[b]ased on these screen prints, ...