NANCY F. ATLAS, District Judge.
This ERISA case is before the Court on the parties' cross-motions for summary judgment. Defendants Coastal Drilling Company, LLC Employee Benefit Trust and Coastal Drilling (collectively, "Coastal Drilling" or "Defendants") filed a Motion for Summary Judgment [Doc. # 35] ("Defendants' Motion") and Plaintiff Memorial Hermann Health System ("MHHS" or "Plaintiff") filed a Response and its own Motion for Summary Judgment [Doc. # 39] ("Plaintiff's Motion").
MHHS instituted this action to collect money it claims it is owed by Coastal
There are five agreements pertinent to the parties' dispute. Pertinent provisions in each are summarized below.
Defendant Coastal Drilling is an employer doing business in Texas. Coastal Drilling provides its employees with medical insurance benefits through a self-funded insurance plan, as defined under the Employee Retirement Income Security Act ("ERISA"), known as the Coastal Drilling Company, LLC Employee Benefit Trust (the "ERISA Plan" or "Plan"). The ERISA Plan is essentially an agreement between Coastal Drilling and the Plan's beneficiaries.
The ERISA Plan also excludes certain payments to providers and limits the total amount of charges available under the Plan. For example, the Plan prohibits payments for "Excess Charges,"
In early 2003, Coastal Drilling entered into a contract with Insurance Systems, Inc. ("ISI"), under which ISI provides administration and coordination services for the ERISA Plan (the "Administrative Services Agreement").
On December 30, 2003, ISI entered into a contract with PPOplus, LLC ("PPOplus") (the "TPA Agreement").
Prior to the TPA Agreement, on January 1, 2002, PPOplus and Healthsmart
A later amendment to the Network Access Agreement grants PPOplus and its clients reciprocal access to HSPC's network of providers.
MHHS is a healthcare provider located in Houston, Texas. On September 1, 2001, MHHS entered into an agreement with HSPC (the "Hospital Service Agreement"). HSPC entered into the agreement as an agent of its clients "to negotiate, monitor and control the purchase of health care services."
Between April 26, 2011, and May 12, 2011, MHHS provided healthcare services to "MF."
MHHS charged $312,655.15 for the services provided and submitted a claim in that amount to Coastal Drilling.
On February 7, 2012, MHHS appealed Coastal Drilling's benefits determination, contending that MHHS was entitled to reimbursement of 80% of its billed charges under its contract with HSPC and requesting payment of a remaining balance of $175,994.65.
On June 22, 2012, MHHS filed a second appeal, again asserting its right to an additional payment of 80% of its billed charges under the Network Access Agreement.
MHHS filed this suit in the 281st Judicial District of Harris County, Texas, on March 27, 2013, and served Defendants on April 15, 2013. Defendants removed the case to this Court on May 2, 2013.
MHHS asserts two claims against Defendants. First, MHHS alleges that Defendants breached a contract between the parties to pay benefits at a certain rate and in a timely fashion.
Rule 56 of the Federal Rules of Civil Procedure mandates the entry of summary judgment, after adequate time for discovery and upon motion, against a party who fails to make a sufficient showing of the existence of an element essential to the party's case, and on which that party will bear the burden at trial. Celotex Corp. v. Catrett, 477 U.S. 317, 322, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986); Little v. Liquid Air Corp., 37 F.3d 1069, 1075 (5th Cir. 1994) (en banc); see also Baton Rouge Oil and Chem. Workers Union v. ExxonMobil Corp., 289 F.3d 373, 375 (5th Cir.2002). Summary judgment "should be rendered if the pleadings, the discovery and disclosure materials on file, and any affidavits show that there is no genuine issue as to any material fact and that the movant is entitled to judgment as a matter of law." FED. R. CIV. P. 56(c); Celotex, 477 U.S. at 322-23, 106 S.Ct. 2548; Weaver v. CCA Indus., Inc., 529 F.3d 335, 339 (5th Cir.2008).
For summary judgment, the initial burden falls on the movant to identify areas essential to the non-movant's claim in which there is an "absence of a genuine issue of material fact." Lincoln Gen. Ins. Co. v. Reyna, 401 F.3d 347, 349 (5th Cir. 2005). The moving party, however, need not negate the elements of the non-movant's case. See Boudreaux v. Swift Transp. Co., 402 F.3d 536, 540 (5th Cir. 2005). The moving party may meet its burden by pointing out "`the absence of evidence supporting the nonmoving party's case.'" Duffy v. Leading Edge Prods., Inc., 44 F.3d 308, 312 (5th Cir.1995) (quoting Skotak v. Tenneco Resins, Inc., 953 F.2d 909, 913 (5th Cir.1992)).
If the moving party meets its initial burden, the non-movant must go beyond the pleadings and designate specific facts showing that there is a genuine issue of material fact for trial. Littlefield v. Forney Indep. Sch. Dist., 268 F.3d 275, 282 (5th Cir.2001) (internal citation omitted). "An issue is material if its resolution could affect the outcome of the action. A dispute
In deciding whether a genuine and material fact issue has been created, the court reviews the facts and inferences to be drawn from them in the light most favorable to the non-moving party. Reaves Brokerage Co. v. Sunbelt Fruit & Vegetable Co., 336 F.3d 410, 412 (5th Cir. 2003). The non-movant's burden is not met by mere reliance on the allegations or denials in the non-movant's pleadings. See King v. Dogan, 31 F.3d 344, 346 (5th Cir. 1994) (holding that unverified pleadings do not "constitute competent summary judgment evidence"). Likewise, "conclusory allegations" or "unsubstantiated assertions" do not meet the non-movant's burden. Delta & Pine Land Co. v. Nationwide Agribusiness Ins. Co., 530 F.3d 395, 399 (5th Cir.2008). Instead, the nonmoving party must present specific facts which show "the existence of a genuine issue concerning every essential component of its case." Am. Eagle Airlines, Inc. v. Air Line Pilots Ass'n, Int'l, 343 F.3d 401, 405 (5th Cir.2003) (citation and internal quotation marks omitted). In the absence of any proof, the court will not assume that the non-movant could or would prove the necessary facts. Little, 37 F.3d at 1075 (citing Lujan v. Nat'l Wildlife Fed'n, 497 U.S. 871, 888, 110 S.Ct. 3177, 111 L.Ed.2d 695 (1990)).
The Court may make no credibility determinations or weigh any evidence, and must disregard all evidence favorable to the moving party that the jury is not required to believe. See Chaney v. Dreyfus Serv. Corp., 595 F.3d 219, 229 (5th Cir.2010) (citing Reaves Brokerage Co., 336 F.3d at 412-413). The Court is not required to accept the non-movant's conclusory allegations, speculation, and unsubstantiated assertions which are either entirely unsupported, or supported by a mere scintilla of evidence. Id. (citing Reaves Brokerage, 336 F.3d at 413). Affidavits cannot preclude summary judgment unless they contain competent and otherwise admissible evidence. See FED. R. CIV. P. 56(c)(4); Love v. Nat'l Med. Enters., 230 F.3d 765, 776 (5th Cir.2000); Hunter-Reed v. City of Houston, 244 F.Supp.2d 733, 745 (S.D.Tex.2003).
Finally, "[w]hen evidence exists in the summary judgment record but the nonmovant fails even to refer to it in the response to the motion for summary judgment, that evidence is not properly before the district court." Malacara v. Garber, 353 F.3d 393, 405 (5th Cir.2003). "Rule 56 does not impose upon the district court a duty to sift through the record in search of evidence to support a party's opposition to summary judgment." See id. (internal citations and quotations omitted).
Congress designed ERISA "to promote the interests of employees and their beneficiaries in employee benefit plans." Shaw v. Delta Air Lines, Inc., 463 U.S. 85, 90, 103 S.Ct. 2890, 77 L.Ed.2d 490 (1983); see also Aetna Health, Inc. v. Davila, 542 U.S. 200, 208, 124 S.Ct. 2488, 159 L.Ed.2d 312 (2004) ("The purpose of ERISA is to provide a uniform regulatory regime over employee benefit plans."). To protect employee rights under the statute, "Congress included various safeguards to preclude abuse and to completely secure the rights and expectations brought into being by this landmark reform legislation." Ingersoll-Rand Co. v. McClendon, 498 U.S. 133,
Congress, through Section 1132(a), created a civil enforcement mechanism that allows participants and beneficiaries of an ERISA plan, among others, to seek relief under the statute by bringing an action "to recover benefits due to him under the terms of his 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." 29 U.S.C. § 1132(a)(1)(B). The Supreme Court has read Section 1132 to preempt "any state-law cause of action that duplicates, supplements, or supplants the ERISA civil enforcement scheme." Davila, 542 U.S. at 210, 124 S.Ct. 2488. This form of preemption, often referred to as "complete preemption,"
At issue here is Section 1144(a), ERISA's "conflict preemption" provision. Under this provision, 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). The Supreme Court has noted that Section 1144(a) is "clearly expansive," but also "recognized that the term `relate to cannot be taken to extend to the furthest stretch of indeterminacy, or else for all practical purposes pre-emption would never run its course." Egelhoff v. Egelhoff ex rel. Breiner, 532 U.S. 141, 146, 121 S.Ct. 1322, 149 L.Ed.2d 264 (2001) (quoting New York State Conference of Blue Cross & Blue Shield Plans v. Travelers Ins. Co., 514 U.S. 645, 655, 115 S.Ct. 1671, 131 L.Ed.2d 695 (1995)) (internal quotations omitted). Accordingly, the Supreme Court has held "that a state law relates to an ERISA plan if it has a connection with or reference to such a plan." Id. (quoting Shaw, 463 U.S. at 97, 103 S.Ct. 2890). A court must look to "the objectives of the ERISA statute as a guide to the scope of the state law that Congress understood would survive, as well as to the nature of the effect of the state law on ERISA plans." Id. (quoting California Div. of Labor Standards Enforcement v. Dillingham Constr., N.A., Inc., 519 U.S. 316, 325, 117 S.Ct. 832, 136 L.Ed.2d 791 (1997)).
The Fifth Circuit has articulated a more definite test to assess whether Section 1144(a) preempts state law. To establish conflict preemption, a defendant must prove: "(1) the state law claims address an area of exclusive federal concern, such as the right to receive benefits under the terms of an ERISA plan; and (2) the claims directly affect the relationship among traditional ERISA entities — the employer, the plan and its fiduciaries, and the participants and beneficiaries." Memorial Hospital System v. Northbrook Life Ins. Co., 904 F.2d 236, 245 (5th Cir. 1990); see also Access Mediquip L.L.C. v. UnitedHealthcare Ins. Co., 662 F.3d 376, 382 (5th Cir.2011) (quoting Northbrook).
Under the Fifth Circuit's test, ERISA does not preempt MHHS's breach of contract claim. In this case, MHHS sues Coastal Drilling for breach of contract, i.e., failure to pay benefits in accordance with rates MHHS contracted with HSPC. MHHS seeks to enforce a provision of the Network Access Agreement against Coastal Drilling, not enforce the ERISA Plan. The claim here is not derived from MHHS's right to receive benefits under the ERISA Plan, and does not "address an area of exclusive federal concern." See Central States, Southeast and Southwest Areas Health and Welfare Fund v. Health Special Risk, Inc., 2013 WL 2656159, at *3 (N.D.Tex. June 13, 2013) ("The goal of [the] suits ... would not be to recover plan benefits or to complain about plan administration but to obtain non-ERISA contractual benefits; determining the amount of benefits to be paid by the ERISA plan (as opposed to the contract) would not be the object of the suit."); North Cypress Medical Center Operating Co. v. CIGNA Healthcare, 782 F.Supp.2d 294, 313 (S.D.Tex.2011) (Ellison, J.) ("Cigna's obligation to pay North Cypress the specified amounts derives from the terms of the `Discount Agreements' and, thus, CIGNA's alleged breach of the contracts implicates an independent legal duty .... Because the Discount Agreements create a legal duty apart from the ERISA plans and resolution of the claim does not necessarily require interpretation of the plan, North Cypress' breach of contract claim is not preempted by ERISA."). The case at bar is similarly distinguishable from other cases where plaintiffs seek to enforce a provision of an ERISA plan through a state law breach of contract claim, a claim that would be preempted. See, e.g., Gonzalez v. AutoZone, Inc., 776 F.Supp.2d 405, 411 (S.D.Tex.2011). In short, MHHS's contract claim for breach of the Network Access Agreement is a state law cause of action that could not have been brought pursuant to ERISA, and is not preempted by Section 1144(a). See also Access Mediquip, 662 F.3d at 385-86 ("State law claims of the kind asserted ... concern the relationship between the plan and third-party, non-ERISA entities [regarding expected payments] ... [which] is not a domain of behavior that Congress intended to regulate with the passage of ERISA ...").
The cases that Coastal Drilling cites in support of its preemption argument are distinguishable. In Memorial Hermann Hospital System v. UnitedHealthcare Insurance Company ("UnitedHealthcare"), Judge Lee Rosenthal held that the plaintiff's breach of contract claim was preempted because determining whether the contract was breached required consulting "the administrative record to determine whether the claims were excluded under the relevant ERISA plan terms." 2012 WL 92563, at *3 (S.D.Tex. Jan. 11, 2012). At issue in that case, however, was a determination of the right to payment for medical services that allegedly were limited by the ERISA plan. As Judge Rosenthal noted, "ERISA preempts the
The discussion in Northbrook is inapplicable for the same reasons. The Fifth Circuit there affirmed dismissal of plaintiff's state law claims that were asserted "as an assignee of" the patient, for whom medical insurance coverage was denied. See Northbrook, 904 F.2d at 250. Here, on the other hand, MHHS sues Coastal Drilling in the breach of contract claim in MHHS's own right under the Network Access Agreement; MHHS's claim is not derivative of MF's rights under the ERISA Plan.
Reference to the ERISA Plan in the TPA Agreement as a measure of benefits or damages is also insufficient to trigger preemption. Defendants admit they are bound to the TPA Agreement, which obligates them to "pay claims of Participating Providers in accordance with the applicable Plan and the PPO Contracted Rates."
MHHS's breach of contract claim is not, as Defendants term it, "a collateral attack on the Plan's correct benefit determination" or a "end run around ERISA."
MHHS, a non-party to the Network Access Agreement, seeks to enforce that agreement against Coastal Drilling, another non-party to the agreement.
In order to prevail on a breach of contract claim under Texas law, a plaintiff must establish the existence of a contract, the performance or tender of performance by the plaintiff, a breach by the defendant and damages as a result of that breach. Bridgmon v. Array Sys. Corp., 325 F.3d 572, 577 (5th Cir.2003) (citing Frost Nat'l Bank v. Burge, 29 S.W.3d 580, 593 (Tex.App.-Houston [14th Dist.] 2000, no pet.)). A breach occurs when a party fails or refuses to do something he has promised to do. Townewest Homeowners Ass'n, Inc. v. Warner Communication Inc., 826 S.W.2d 638, 640 (Tex.App.-Houston [14th Dist.] 1992, no writ); Intermedics, Inc. v. Grady, 683 S.W.2d 842, 845 (Tex.App.-Houston [1st Dist.] 1984, writ ref'd n.r.e.).
MHHS asserts that Defendants breached Section 11 of the Network Access Agreement. As stated above, the Network Access Agreement is a contract between PPOplus and HSPC governing the relationship between those parties and providing access by each party's "Clients" into the other party's network of providers. Section 11 of that agreement provides, in part, that each party "shall require client to pay claims of Participating Providers in accordance with the applicable Plan and the [other party's] Contracted Rates."
Defendants, in contrast, assert that Section 11 is unenforceable against them, because "Defendants can only be held liable for breaching obligations they incurred."
Both parties here agree that, generally speaking, Texas law permits multiple contracts to be read together to comprise a single contract.
In Baylor University Medical Center v. Epoch Group, L.C., 340 F.Supp.2d 749 (N.D.Tex.2004), Judge A. Joe Fish considered a set of interconnected contracts similar to the circumstances at bar. There, Baylor University Medical Center and other plaintiffs (collectively, "Baylor") brought a breach of contract claim against Epoch Group, L.C. ("Epoch"), alleging that Epoch had failed to pay for certain medical services Baylor had rendered for a participant of an ERISA plan that Epoch supervised. Id. at 751-52. Epoch previously had entered into a contract with Private Healthcare Systems, Inc. ("PHCS"), pursuant to which "Epoch received financial incentives to encourage participants in the Plan to choose treatment from medical providers in the PHCS network of providers." Id. at 752. Baylor had signed an agreement with PHCS to join the latter's network of providers. Id. Finally, Epoch signed a "Payor Acknowledgment" under which it contracted to pay PHCS providers under the terms of PHCS's contracts with those providers. Id. at 752.
Judge Fish held that, under Texas law, the contracts at issue could be read as one. See id. at 754-56. Judge Fish noted that "the instruments expressly refer to one another, showing an intertwined relationship between the parties and the instruments at issue." Id. at 755. Moreover, the court noted that the Payor Acknowledgment, which Epoch signed, "acknowledges the contracts between PHCS and health care providers such as Baylor ... [and] expressly requires Payors to pay for health care services and to comply with preferred providers agreements." Id. By agreeing to assume Payor status, the court concluded, "Epoch assumed both rights — i.e., the right to discounts for medical services
The Court concludes that MHHS cannot enforce the Network Access Agreement against Defendants. This case differs from Epoch in two significant ways.
Second, MHHS is not a party to the Network Access Agreement, the contract it seeks to enforce, and that agreement expressly disclaims an intent that third-parties obtain enforceable contractual rights under it.
It is true that Coastal Drilling's entry into the TPA Agreement presumed that PPOplus (or HSPC, through the Network Access Agreement) would enter into contracts with health care providers to create a network of providers that Coastal Drilling could access.
Accordingly, because MHHS, as a matter of law, cannot enforce the Network Access Agreement against Coastal Drilling, the Court denies MHHS's Motion for Summary Judgment and grants Coastal Drilling's Motion for Summary Judgment as to MHHS's breach of contract claim.
MHHS also contends that Coastal Drilling failed to pay it proper benefits under the terms of the ERISA Plan for services MHHS rendered to MF, and brings a claim pursuant to 29 U.S.C. § 1132(a)(1)(B) to recover those benefits.
A plaintiff may bring an action under ERISA "to recover benefits due to him under the terms of his 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." 29 U.S.C. § 1132(a)(1)(B). Where an ERISA plan gives a plan administrator "discretionary authority to determine eligibility for benefits," a district court reviews an eligibility
The Supreme Court has warned, however, that where "a benefit plan gives discretion to an administrator or fiduciary who is operating under a conflict of interest, that conflict must be weighed as a factor in determining whether there is an abuse of discretion.'" Metro. Life Ins. Co., 554 U.S. at 111, 128 S.Ct. 2343 (quoting Firestone, 489 U.S. at 115, 109 S.Ct. 948) (emphasis in original). In Metropolitan Life Insurance Company, the Supreme Court held a conflict of interest arises where an employer "both funds the plan and evaluates the claims," because "[t]he employer's fiduciary interest may counsel in favor of granting a borderline claim while its immediate financial interest counsels to the contrary." Id. at 112, 128 S.Ct. 2343; see also Truitt, 729 F.3d at 508 ("A plan administrator has a conflict of interest if it both evaluates claims for benefits and pays benefits claims." (internal quotations omitted)). In elucidating how courts should assess this "factor," the Supreme Court noted that, like any other factor in the equation, the fact of a conflict could "act as a tiebreaker when the other factors are closely balanced." Id. at 117, 128 S.Ct. 2343. Moreover, the Court stated that the factor's import depends on the circumstances: it is more important "where circumstances suggest a higher likelihood that it affected the benefits decision," and is less important "where the administrator has taken active steps to reduce potential bias and to promote accuracy." Id.; see also Truitt, 729 F.3d at 508-09 (citing Metro Life Ins. Co.).
Coastal Drilling both funds the ERISA Plan and acts as its administrator and fiduciary.
Moreover, Coastal Drilling has assigned ELAP "discretionary authority and ultimate decision-making authority with respect to any appeals or denied claims" and
The Court assumes Coastal Drilling and ELAP are to be viewed as a single entity for purposes of ascertaining if a conflict exists. The Court will therefore factor in the conflict in determining the merits of the claim.
Coastal Drilling maintains that the ERISA Plan permits it only to pay benefits within APL, and no benefits in excess of APL.
MHHS does not meaningfully contest the merits of the reasoning behind Coastal Drilling's benefits determination under the Plan. Indeed, MHHS does not provide any alternate calculation of the APL, nor does it suggest any other method of calculating benefits pursuant to the ERISA Plan. Instead, MHHS relies on other contracts (namely, the Network Access Agreement) to argue that the PPO Contracted Rates, rather than the APL, should govern the benefits determination.
Even if MHHS had contested the factual reasoning of Coastal Drilling's benefits determination under the language of the Plan, Coastal Drilling is entitled to summary judgment on MHHS's ERISA claim. There is substantial evidence to support
Accordingly, the Court grants Defendants' Motion for Summary Judgment as to MHHS's ERISA claim.
For the reasons stated above, the Court has jurisdiction to address MHHS's breach of contract claim, which is not preempted. The Court concludes that MHHS, a non-party to the Network Access Agreement, cannot enforce the terms of that agreement against Coastal Drilling, another non-party to that agreement. Moreover, MHHS has failed to demonstrate a genuine fact issue concerning Coastal Drilling's evaluation of the claims MHHS has submitted. It is therefore
A separate final judgment will be issued.