Howard v. Group Hosp. Service
Citation | 739 F.2d 1508 |
Decision Date | 06 August 1984 |
Docket Number | No. 82-1397,82-1397 |
Parties | Lloyde E. HOWARD, Plaintiff-Appellant, v. GROUP HOSPITAL SERVICE, an Oklahoma Corporation, d/b/a Blue Cross and Blue Shield of Oklahoma, Defendant-Appellee. |
Court | United States Courts of Appeals. United States Court of Appeals (10th Circuit) |
Donald R. Wilson of Fenton, Fenton, Smith, Reneau & Moon, Oklahoma City, Okl. and Porta, Bass & Bass, El Reno, Okl., for plaintiff-appellant.
E. Bryan Henson of Chapel, Wilkinson, Riggs, Abney & Henson, Tulsa, Okl., for defendant-appellee.
Before BARRETT, DOYLE and LOGAN, Circuit Judges.
Plaintiff Lloyde E. Howard brought suit against Group Hospital Service, d/b/a Blue Cross and Blue Shield of Oklahoma (Blue Cross), in an Oklahoma state court for damages in tort and contract resulting from Blue Cross' failure to pay claims under a Federal Employee Health Benefits Program (FEP) medical insurance policy. Blue Cross refused to pay a portion of claims made for treatment of Howard's wife for nervous and mental problems on the basis that there was no medical necessity for the treatment. Blue Cross removed the case to the United States District Court, alleging federal question jurisdiction under 28 U.S.C. Sec. 1441(b). The federal district court denied plaintiff's motion to remand the case. Howard appeals from a jury verdict awarding him $1,649.00. The cause was submitted on the briefs by agreement of the parties. Because we find that the trial court did not have subject matter jurisdiction, we consider only this jurisdictional issue and order that the case be returned to the trial court for remand to the state court.
Under 5 U.S.C. Secs. 8901-13 the Office of Personnel Management (OPM) contracts for and approves health benefit plans covering federal employees. The federal government subsidizes the subscription charge, but never pays more than seventy-five percent of a participant's costs. 5 U.S.C. Sec. 8906(b). Blue Cross has a contract with the OPM setting forth an approved plan. Howard chose the Blue Cross option and hence is a third party beneficiary of the contract between Blue Cross and the federal government. He is also a contracting party because he pays for medical coverage.
Blue Cross argues, citing Clearfield Trust Co. v. United States, 318 U.S. 363, 63 S.Ct. 573, 87 L.Ed. 838 (1943), that because a government agency is a party to the FEP contract, federal law should apply to the interpretation of the medical necessity provision to promote uniformity of decision and interpretation of the contract. In Clearfield the federal government brought suit seeking reimbursement for funds paid to Clearfield Trust Company. Clearfield, as agent for J.C. Penney Company, negotiated a government check issued to an individual without knowledge that the payee's endorsement had been forged. The district court applied Pennsylvania law to bar the government from recovering because the government had unnecessarily delayed in giving notice of the forgery to Clearfield Trust. The Supreme Court held that the district court erroneously applied state law because the "rights and duties of the United States on commercial paper which it issues are governed by federal rather than local law." Id. at 366, 63 S.Ct. at 575. The Court stated, "The authority to issue the check had its origin in the Constitution and the statutes of the United States and was in no way dependent on the laws of Pennsylvania or of any other state." Id.
But, in this case, the resolution of petitioners' breach-of-contract claim against the respondent will have no direct effect upon the United States or its Treasury. The Solicitor General, waiving his right to respond in these cases, advised us:
The operations of the United States in connection with FAA grants such as these are undoubtedly of considerable magnitude. However, we see no reason for concluding that these operations would be burdened or subjected to uncertainty by variant state-law interpretations regarding whether those with whom the United States contracts might be sued by third-party beneficiaries to the contracts. Since only the rights of private litigants are at issue here, we find the Clearfield Trust rationale inapplicable."
Id. at 28-30, 97 S.Ct. at 2493-94 (footnotes omitted). See also Bank of America Nat. Trust & Sav. Ass'n v. Parnell, 352 U.S. 29, 33-34, 77 S.Ct. 119, 121, 1 L.Ed.2d 93 (1956). Similarly, in the case at bar the federal government is responsible for contracting for or approving health benefits plans, 5 U.S.C. Sec. 8903, but the FEP would not be significantly hindered by different state law interpretations of the medical necessity provision in the Blue Cross plan nor would disputes regarding those provisions involve anyone but private litigants.
Id. at 432. Unlike Carson, a suit brought under an FEP policy for denial of a claim based on lack of medical necessity is not against the United States and does not seek funds from the United States Treasury. Further, the dispute in Carson arose out of the Bankhead-Jones Farm Tenant Act, which established an extensive federal lending program to promote the efficient and productive use of agricultural resources. The act requires that the government loans be adequately secured. 7 U.S.C. Sec. 1946. Also a uniform federal rule governing the liability of livestock brokers dealing tortiously with mortgaged property helps prevent the unjustifiable defeat of United States security interests. 372 F.2d at 433. The same concerns are not involved in the case at bar.
As we understand Clearfield, Miree, and Parnell, when the federal government has an articulable interest in the outcome of a dispute, federal law governs. Thus, if diverse resolutions of a controversy would frustrate the operations of a federal program, see Carson, 372 F.2d at 432, conflict with a specific national policy, see Bartsch v. Metro-Goldwyn-Mayer, Inc., 391 F.2d 150, 153 (2d Cir.), cert. denied, 393 U.S. 826, 89 S.Ct. 86, 21 L.Ed.2d 96 (1968), 1 or have some direct effect on the United States or its treasury, then federal law applies.
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