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                                                                     [PUBLISH]

            IN THE UNITED STATES COURT OF APPEALS

                    FOR THE ELEVENTH CIRCUIT
                      ________________________

                            No. 19-13088
                      ________________________

                  D.C. Docket No. 4:18-cv-00158-HLM



HASMUKH PATEL, M.D.,

                                                            Plaintiff-Appellant,

                                   versus



HAMILTON MEDICAL CENTER, INC.,

                                                        Defendant-Appellee.

                      ________________________

               Appeal from the United States District Court
                  for the Northern District of Georgia
                     ________________________

                              (July 30, 2020)

Before WILLIAM PRYOR, Chief Judge, ROSENBAUM and LUCK, Circuit
Judges.

WILLIAM PRYOR, Chief Judge:
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      This appeal requires us to decide whether a plaintiff may invoke the subject-

matter jurisdiction of a district court by seeking a declaratory judgment that a

defendant enjoys no immunity from damages under a federal statute. After

Hamilton Medical Center, Inc., suspended his medical staff privileges, Hasmukh

Patel filed a complaint against the Medical Center that sought damages, an

injunction against the suspension, and a declaration that the Health Care Quality

Improvement Act, 42 U.S.C. § 11111(a)(1), provided no immunity from damages

to the Medical Center. Patel contended that the district court had federal-question

jurisdiction over the request for declaratory relief and could exercise supplemental

jurisdiction over his remaining claims, all of which arose under state law. The

district court granted summary judgment in favor of the Medical Center. Because

Patel’s request for a declaratory judgment does not fall within federal-question

jurisdiction, we vacate the judgment against him and remand with instructions to

dismiss his complaint for lack of subject-matter jurisdiction.

                                I. BACKGROUND
      Patel is a gastroenterologist in Dalton, Georgia, who has held medical staff

privileges at the Medical Center since 1982. The Medical Center, which is also

located in Dalton, conditioned Patel’s privileges on his compliance with its bylaws

and Credentials Policy. The Credentials Policy required Patel to be available to

provide care for or to otherwise arrange coverage for his patients at all times.



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      This litigation concerns a suspension that the Medical Center levied against

Patel for allegedly failing to provide coverage over his Thanksgiving vacation in

November 2014. After a physician reported the gap to administrators from the

Medical Center, two standing committees recommended suspending Patel’s

privileges for more than 30 days. Patel, who insisted that he arranged coverage

during his vacation, demanded a hearing. The hearing panel upheld the

recommendation of the standing committees. Patel then appealed to a review panel,

which reduced his suspension to 29 days but otherwise upheld the recommendation

of the hearing panel.

      Patel filed a complaint against the Medical Center that sought damages and

injunctive relief under state law and a declaratory judgment that the Medical

Center was not immune from damages under the Health Care Quality Improvement

Act. See 42 U.S.C. § 11111(a)(1) (providing hospitals with immunity from

damages that arise out of certain peer-review proceedings). Patel alleged that the

district court had federal-question jurisdiction over his request for declaratory

relief, 28 U.S.C. § 1331, and that it could exercise supplemental jurisdiction over

his claims under state law

district court granted the Medical Center’s motion for summary

judgment. It ruled that the Health Care Quality Improvement Act provided

immunity from damages to the Medical Center, that each of Patel’s state-law



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claims failed on the merits, and that Patel abandoned several of those claims. Patel

appealed only the ruling on his request for declaratory relief.

                          II. STANDARD OF REVIEW

      “The district court’s subject matter jurisdiction is a question of law that we

review de novo.” United States v. Iguaran, 

, 1336 (11th Cir. 2016).

                                 III. DISCUSSION

       “Longstanding principles of federal law oblige us to inquire sua sponte

whenever a doubt arises as to the existence of federal jurisdiction.” Green v.

Graham, 

, 961 (11th Cir. 2018) (internal quotation marks omitted).

As inferior courts, federal circuit and district courts are “empowered to hear only

those cases within the judicial power of the United States as defined by Article III

of the Constitution[] and which have been entrusted to them by a jurisdictional

grant authorized by Congress.” Univ. of S. Ala. v. Am. Tobacco Co., 

,

409 (11th Cir. 1999) (internal quotation marks omitted); see also Bryan A. Garner

et al., The Law of Judicial Precedent § 65, at 551 (2016). In other words, an

inferior court’s jurisdiction “must be both (1) authorized by statute and (2) within

constitutional limits.” OFS Fitel, LLC v. Epstein, Becker & Green, P.C., 

, 1355 (11th Cir. 2008).

      The record gives rise to questions both about whether statutory jurisdiction

exists over this action, see 28 U.S.C. § 1331, and about whether this appeal



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presents a justiciable controversy, see U.S. Const. art. III. For statutory

jurisdiction, Patel contends only that federal-question jurisdiction exists over his

suit, but a request for declaratory relief that a federal law does not entitle the

opposing party to a defense ordinarily does not raise a federal question under

section 1331. See First Fed. Sav. & Loan Ass’n of Lake Worth v. Brown, 

, 1220 (11th Cir. 1983). And Patel may have deprived us of Article III

jurisdiction when he appealed the denial of his request for a declaratory judgment

without also challenging the ruling of the district court on his only claim that

requested damages. Without an active claim that could produce damages, Patel

might not have a legally cognizable interest in receiving a declaration that the

Health Care Quality Improvement Act does not shield the Medical Center from

damages. See Genesis Healthcare Corp. v. Symczyk, 

, 72 (2013)

(holding that a case is moot if “an intervening circumstance deprives the plaintiff

of a personal stake in the outcome of the lawsuit” (internal quotation marks

omitted)).

      Although mootness implicates our jurisdiction under Article III, we can

resolve this appeal on either jurisdictional ground. Even if mootness deprives us of

jurisdiction to reach the merits, Article III leaves intact our statutory authority “to

enter orders necessary and appropriate to the final disposition of a suit that is

before us for review.” U.S. Bancorp Mortg. Co. v. Bonner Mall P’ship, 

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18, 21–22 (1994); see also 28 U.S.C. § 2106 (“[A]ny . . . court of appellate

jurisdiction may . . . vacate . . . any judgment, decree, or order of a court lawfully

brought before it for review, and may remand the cause and direct the entry of such

appropriate judgment . . . .”). And so “[i]f a judgment has become moot while

awaiting review, [we] may not consider its merits, but may make such disposition

of the whole case as justice may require.” 

(alteration

adopted) (quoting Walling v. James V. Reuter, Inc., 

, 677 (1944)). In

other words, we may “choose among threshold grounds for denying audience to a

case on the merits” in this Court. Gardner v. Mutz, 

, 1336–38 (11th

Cir. 2020) (internal quotation marks omitted) (vacating the judgment of the district

court on standing grounds without resolving whether the suit became moot on

appeal).

      In the light of this discretion, we start and end with the question of statutory

jurisdiction. Because the Declaratory Judgment Act does not enlarge our

jurisdiction, the plaintiff must still assert “an underlying ground for federal court

jurisdiction.” Household Bank v. JFS Grp., 

, 1253 (11th Cir. 2003);

see also 28 U.S.C. § 2201(a) (empowering district courts to enter declaratory

judgments in “case[s] of actual controversy within [their] jurisdiction”). As

discussed, Patel contends that his request for declaratory judgment establishes

federal-question jurisdiction. See 28 U.S.C. § 1331. He does not raise any other



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possible ground for statutory jurisdiction. Although Patel’s request for declaratory

judgment turns on an issue of federal law, “we do not look to the face of the

declaratory judgment complaint in order to determine the presence of a federal

question.” Hudson Ins. Co. v. Am. Elec. Corp., 

, 828 (11th Cir. 1992).

Federal-question jurisdiction exists “over a declaratory judgment action if . . . a

plaintiff’s well-pleaded complaint alleges facts demonstrating the defendant could

file a coercive action arising under federal law.” Household 

.

        Patel’s complaint does not establish that the Medical Center could file a

coercive action under federal law. The Health Care Quality Improvement Act—the

only federal law at issue—does not create a private right of action. See Bok v. Mut.

Assurance, Inc., 

, 929 (11th Cir. 1997). It creates an affirmative

defense from damages. See Bryan v. James E. Holmes Reg’l Med. Ctr., 

, 1332–33 (11th Cir. 1994). And a plaintiff cannot create federal-question

jurisdiction by seeking a declaration that a federal defense does not protect the

defendant. See Skelly Oil Co. v. Phillips Petroleum Co., 

, 673–74

(1950) (refusing to “sanction suits for declaratory relief as within the jurisdiction

of the District Courts merely because . . . artful pleading anticipates a defense

based on federal law”); 

(“A case does not present a

federal question of the sort necessary to confer subject matter jurisdiction . . .



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where it merely anticipates a federal question defense which the defendant might

raise . . . .”). So Patel’s request for declaratory judgment does not establish federal-

question jurisdiction.

      Patel contends that “he could be forced to defend a claim for liability for

expenses of litigation under” the Health Care Quality Improvement Act, but he

misinterprets the Act. The Act allows a court to award attorney’s fees “at the

conclusion of the action” in some circumstances. 42 U.S.C. § 11113. Because

Congress tied this provision to the underlying suit, the Medical Center could not

“file a coercive action” for attorney’s fees. Household 

.

      Patel also alleges that his suit “requires interpretation of a substantial federal

issue and a substantial question of federal law,” but we would lack jurisdiction

even if this allegation were true. To be sure, “federal jurisdiction over a state law

claim will lie if a federal issue is: (1) necessarily raised, (2) actually disputed, (3)

substantial, and (4) capable of resolution in federal court without disrupting the

federal-state balance approved by Congress.” Gunn v. Minton, 

, 258

(2013). But to reiterate, our jurisdiction turns on whether the Medical Center

“could file a coercive action arising under federal law,” Household 

, and Patel’s complaint does not establish that the Medical Center could

bring any claim against him, much less one that satisfies these four conditions. Cf.

Iberiabank v. Beneva 41-I, LLC, 

, 919 n.4 (11th Cir. 2012) (holding



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that the district court had jurisdiction over a declaratory-judgment action because

the defendant “likely could bring its own state contract claim, which would

necessarily raise a federal question”). Nor do we see how a state claim could ever

“necessarily raise” a federal issue under the Health Care Quality Improvement Act,

which creates only an affirmative defense. 

–59 (examining

whether the elements of a claim under state law would implicate a federal

question); Adventure Outdoors, Inc. v. Bloomberg, 

, 1297–98 (11th

Cir. 2008) (holding that a claim under state law did not did not necessarily raise a

federal issue when its elements did not implicate federal law). After all, affirmative

defenses do not necessarily arise in suits. A defendant can forfeit an affirmative

defense by failing to raise it, and “[a]n affirmative defense, once forfeited, is

excluded from the case.” Wood v. Milyard, 

, 470 (2012) (alteration

adopted) (internal quotation marks omitted).

      The district court lacked jurisdiction over this suit. Patel has not met his

burden to establish federal-question jurisdiction, and we see no other possible

avenue for statutory jurisdiction. In the light of this defect, we need not address

mootness and cannot consider the merits of this appeal.




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                                 IV. CONCLUSION

      We VACATE the judgment in favor of the Medical Center and REMAND

with instructions to DISMISS Patel’s complaint for lack of subject-matter

jurisdiction.




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