Filed: Mar. 02, 2016
Latest Update: Mar. 02, 2020
Summary: Third District Court of Appeal State of Florida Opinion filed March 02, 2016. Not final until disposition of timely filed motion for rehearing. _ No. 3D15-983 Lower Tribunal No. 14-17569 _ La Ley Recovery Systems-OB, Inc., a/a/o Dr. Olivio Blanco, Jr., Appellant, vs. United Healthcare Insurance Company, Appellee. An Appeal from the Circuit Court for Miami-Dade County, Bronwyn C. Miller, Judge. Law Offices of La Ley con John H. Ruiz, P.A., and John H. Ruiz, Timothy J. Van Name, and Christine M. L
Summary: Third District Court of Appeal State of Florida Opinion filed March 02, 2016. Not final until disposition of timely filed motion for rehearing. _ No. 3D15-983 Lower Tribunal No. 14-17569 _ La Ley Recovery Systems-OB, Inc., a/a/o Dr. Olivio Blanco, Jr., Appellant, vs. United Healthcare Insurance Company, Appellee. An Appeal from the Circuit Court for Miami-Dade County, Bronwyn C. Miller, Judge. Law Offices of La Ley con John H. Ruiz, P.A., and John H. Ruiz, Timothy J. Van Name, and Christine M. Lu..
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Third District Court of Appeal
State of Florida
Opinion filed March 02, 2016.
Not final until disposition of timely filed motion for rehearing.
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No. 3D15-983
Lower Tribunal No. 14-17569
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La Ley Recovery Systems-OB, Inc., a/a/o Dr. Olivio
Blanco, Jr.,
Appellant,
vs.
United Healthcare Insurance Company,
Appellee.
An Appeal from the Circuit Court for Miami-Dade County, Bronwyn C.
Miller, Judge.
Law Offices of La Ley con John H. Ruiz, P.A., and John H. Ruiz, Timothy
J. Van Name, and Christine M. Lugo, for appellant.
GrayRobinson, P.A., and Daniel Alter, Shari Gerson, Jeffrey T. Kuntz, Evan
D. Appell, and Shayna Freyman (Fort Lauderdale), for appellee.
Before ROTHENBERG, EMAS, and FERNANDEZ, JJ.
ROTHENBERG, J.
The plaintiff, La Ley Recovery Systems-OB, Inc., a/a/o Dr. Olivio Blanco,
Jr. (“La Ley”), appeals an order dismissing with prejudice its amended complaint
filed against United Healthcare Insurance Company (“United”). We affirm
because (1) the health plan clearly provides that United will not reimburse third
parties, such as La Ley, that have been assigned benefits by a provider, and (2) La
Ley’s state-law claims, which “relate to” a health plan governed by the Employee
Retirement Income Security Act of 1974 (“ERISA”), are defensively preempted
under section 514(a) of ERISA.
La Ley filed an amended complaint against United asserting that Dr. Olivio
Blanco, Jr. (“Dr. Olivio”) provided services to a patient insured under United’s
health plan. Prior to providing services to the patient, Dr. Blanco contacted United
to verify coverage, and United expressly and impliedly represented to Dr. Blanco
that the services were covered and that United would fully compensate Dr. Blanco
for the services according to the pre-established rate of payment. After treating the
patient, Dr. Blanco submitted the claims to United, but United failed to fully
compensate Dr. Blanco. Thereafter, Dr. Blanco assigned his claims to La Ley.
Based on these allegations, La Ley asserted six state-law claims against United—
negligent misrepresentation, fraudulent misrepresentation, fraud in the inducement,
breach of oral agreement, breach of implied contract in fact, promissory estoppel,
and unjust enrichment.
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United moved to dismiss La Ley’s amended complaint on two primary
grounds. First, United argued that La Ley does not have standing to bring the
action because the health plan does not permit assignments to third parties based
on the following provision:
Payment of Benefits
If a Subscriber provides written authorization to allow this, all or a
portion of any Eligible Expenses due to a provider may be paid
directly to the provider instead of being paid to the Subscriber. But
we will not reimburse third parties that have purchased or been
assigned benefits by Physicians or other providers.
(Emphasis added) (hereinafter referred to as “the payment of benefits provision”).
Second, United argued that even if La Ley had standing, La Ley’s state-law claims
are defensively preempted under section 514(a) of ERISA because all of La Ley’s
claims “relate to” an ERISA-governed health plan.
Following a hearing on United’s motion to dismiss La Ley’s amended
complaint, the trial court granted the motion to dismiss with prejudice based on the
payment of benefits provision in the health plan and defensive preemption. This
appeal followed.
In the instant case, Dr. Blanco allegedly assigned his rights to collect any
unpaid benefits due from United to La Ley. Although the health plan specifically
states that United “will not reimburse third parties that have purchased or been
assigned benefits by Physicians or other providers,” La Ley contends that the
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payment of benefits provision in the health plan is ambiguous, and therefore, not
enforceable. We disagree. The payment of benefits provision is not ambiguous
because it is not “susceptible to more than one reasonable interpretation.” State
Farm Mut. Auto. Ins. Co. v. Menendez,
70 So. 3d 566, 570 (Fla. 2011) (internal
quotations omitted). Although the payment of benefits provision permits a
subscriber to assign benefits to the provider upon written authorization, the
provision specifically precludes the physician or other provider from further
assigning the benefits to third parties, such as La Ley. Therefore, the trial court
correctly dismissed with prejudice La Ley’s amended complaint. See Kohl v. Blue
Cross & Blue Shield of Fla., Inc.,
955 So. 2d 1140, 1143 (Fla. 4th DCA 2007)
(holding that a court may enforce insurance policy provisions that clearly and
unambiguously preclude assignment).
Although the order dismissing the amended complaint with prejudice can be
affirmed based solely on the application of the payment of benefits provision, we
briefly address and reject La Ley’s contention that its state-law claims are not
defensively preempted by ERISA. “[D]efensive preemption provides an
affirmative defense to certain state law claims and calls for their dismissal where
the state claim ‘relates’ to an ERISA plan.” Bertoni v. Stock Bldg. Supply,
989
So. 2d 670, 674 (Fla. 4th DCA 2008); see also Villazon v. Prudential Health Care
Plan, Inc.,
843 So. 2d 842 (Fla. 2003) (holding that “[i]f a claim relates to the
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manner in which the ERISA plan is administered, ERISA preempts the claim”)
(quoting Villazon v. Prudential Health Care Plan, Inc.,
794 So. 2d 625, 627 (Fla.
3d DCA 2001)). “This defensive preemption doctrine and its ‘relates to’ standard
originate from ERISA’s express preemption provision, 29 U.S.C. § 1144(a).”1
Bertoni, 989 So. 2d at 674.
In the instant case, La Ley does not dispute that the health plan involved in
this case is an ERISA-governed plan. Further, a review of La Ley’s amended
complaint clearly reflects that the state-law claims “relate to” an ERISA-governed
plan. In the amended complaint, La Ley alleges that Dr. Blanco’s patient was
covered under United’s health plan; prior to providing services to the patient, Dr.
Blanco contacted United to verify coverage; United informed Dr. Blanco that the
patient was covered under the health plan; and United represented to Dr. Blanco
that United would fully compensate Dr. Blanco, but United failed to do so. Based
on these allegations, there is no doubt that La Ley’s state-law claims “relate to” the
ERISA-governed health plan because Dr. Blanco’s act of confirming coverage and
1 29 U.S.C. § 1144(a) provides:
(a) Supersedure; effective date
Except as provided in subsection (b) of this section, the provisions of
this subchapter and subchapter III of this chapter shall supersede any
and all State laws insofar as they may now or hereafter relate to any
employee benefit plan described in section 1003(a) of this title and not
exempt under section 1003(b) of this title. This section shall take
effect on January 1, 1975.
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seeking payment under the plan is a by-product of the plan and its provisions.
Accordingly, we conclude that the trial court properly determined that La Ley’s
state-law claims are defensively preempted.
Based on our determinations as to these issues, we find it unnecessary to
address the third ground the trial court relied on in dismissing the amended
complaint with prejudice.
Affirmed.
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