Munda v. Summerlin Life & Health Ins. Co.

• Decision Date: 29 December 2011
• Docket Number: No. 55308.,55308.
• Citation: 127 Nev. Adv. Op. 83,267 P.3d 771
• Court: Nevada Supreme Court
• Parties: Janise MUNDA and Gibb Munda, Appellants, v. SUMMERLIN LIFE & HEALTH INSURANCE COMPANY, Respondent.

127 Nev. Adv. Op. 83

267 P.3d 771

Janise MUNDA and Gibb Munda, Appellants,

v.SUMMERLIN LIFE & HEALTH INSURANCE COMPANY, Respondent.

No. 55308.

Supreme Court of Nevada.

Dec. 29, 2011.

Matthew L. Sharp Ltd. and Matthew L. Sharp, Reno; Friedman Rubin and William S. Cummings, Anchorage, Alaska, for Appellants.

Pisanelli Bice, PLLC, and Todd L. Bice, Debra L. Spinelli, and Jarrod L. Rickard, Las Vegas, for Respondent.

Before the Court En Banc.¹

OPINION

By the Court, DOUGLAS, J.:

In this appeal, we consider whether state law claims of negligence and negligence per se are preempted by the Employee Retirement Income Security Act (ERISA). In a recent opinion, Cervantes v. Health Plan of Nevada, 127 Nev. ––––, 263 P.3d 261 (2011), we concluded that these same claims were preempted; however, this is a fact-intensive inquiry because ERISA preemption is dependent on the actual operation of a state statute. We conclude that under the set of facts alleged before us, there is no preemption because respondent Summerlin Life & Health Insurance Company's alleged actions were independent of the administration of the ERISA plan; therefore, the district court erred in granting Summerlin's motion to dismiss.

FACTS

Respondent Summerlin is an insurer/managed care organization (MCO) doing business in the State of Nevada. As such, Summerlin contracts with medical providers to provide health care services to its insureds. As an MCO, Summerlin is required to have in place a quality assurance program pursuant to NRS 695G.180. Summerlin contracted with the Endoscopy Center of Southern Nevada, the Gastroenterology Center of Nevada, and the doctors employed by or associated with the Gastroenterology Center of Nevada (collectively, the Clinic) to provide health care services to its insureds. Appellants Janise and Gibb Munda allege that from at least 2002 on, Summerlin encouraged its insureds to seek treatment from the Clinic.

Between March 2004 and February 2008, the Clinic engaged in a number of unsafe medical practices, which were ultimately brought to light in early 2008 through an investigation conducted by the Southern Nevada Health District (Health District) and the Centers for Disease Control and Prevention. Summerlin subsequently terminated its contract with the Clinic based on the Health District's findings.

Janise Munda was insured by Summerlin through her employer's health plan, which was governed by ERISA. She sought treatment at the Clinic on February 16, 2007, and March 2, 2007, because it was a Summerlin provider. Janise was later diagnosed with hepatitis C, which the Health District determined she contracted as a result of being treated at the Clinic.

Janise and her husband, Gibb Munda, sued Summerlin for failure to comply with quality assurance standards, with causes of action for negligence, negligence per se, breach of implied covenant of good faith and fair dealing/bad faith, and loss of consortium. The Mundas alleged in their complaint that Summerlin failed to identify the unsafe practices of or terminate its contract with the Clinic sooner because Summerlin failed to evaluate, audit, monitor, and supervise its providers as required by NRS 695G.180.² The Mundas' claims were based on Summerlin's role as an MCO, not on its role as an administrator of an ERISA plan. Summerlin filed a motion to dismiss, arguing that the Mundas' claims were preempted by ERISA. The district court granted Summerlin's motion pursuant to ERISA and NRCP 12(b)(5). The Mundas now appeal that decision.

DISCUSSION

On appeal, the Mundas argue that the district court erred in dismissing their complaint as preempted by ERISA because their claims ³ do not fall under ERISA's preemption provisions, sections 502(a) and 514(a) (codified at 29 U.S.C. §§ 1132(a) and 1144(a), respectively), which generally preclude state law claims relating to an employee benefit plan. Specifically, the Mundas argue that their claims are unrelated to the administration of the ERISA plan and, as such, their claims cannot be preempted by ERISA sections 502(a) or 514(a) because Congress did not intend to use ERISA to preempt health and safety matters traditionally left to state regulation. We agree as to ERISA section 514(a).⁴

Standard of review

A district court order granting an NRCP 12(b)(5) motion to dismiss is subject to rigorous appellate review. Similar to the trial court, this court accepts the plaintiffs' factual allegations as true, but the allegations must be legally sufficient to constitute the elements of the claim asserted. In reviewing the district court's dismissal order, every reasonable inference is drawn in the plaintiffs' favor.Sanchez v. Wal–Mart Stores, 125 Nev. 818, 823, 221 P.3d 1276, 1280 (2009) (internal citations omitted). This court reviews de novo a district court's order granting a motion to dismiss, and such an order will not be upheld “ ‘unless it appears beyond a doubt that the plaintiff could prove no set of facts ... [that] would entitle him [or her] to relief.’ ” Vacation Village v. Hitachi America, 110 Nev. 481, 484, 874 P.2d 744, 746 (1994) (quoting Edgar v. Wagner, 101 Nev. 226, 228, 699 P.2d 110, 112 (1985)); see Sanchez, 125 Nev. at 823, 221 P.3d at 1280.

Preemption under ERISA section 514(a)

“Congress enacted ERISA to ‘protect ... the interests of participants in employee benefit plans and their beneficiaries,’ by setting out substantive regulatory requirements for employee benefit plans, and to ‘provide for appropriate remedies, sanctions, and ready access to federal courts.’ ” Insco v. Aetna Health & Life Ins. Co., 673 F.Supp.2d 1180, 1185 (2009) (quoting Aetna Health Inc. v. Davila, 542 U.S. 200, 208, 124 S.Ct. 2488, 159 L.Ed.2d 312 (2004)). As part of the enactment, ERISA has “expansive preemption provisions that are intended to ensure that employee benefit plan regulation is ‘exclusively a federal concern.’ ” Id. (quoting Aetna Health, 542 U.S. at 208, 124 S.Ct. 2488). “[The United States] Supreme Court has repeatedly held that the question of whether federal law preempts state law is one of congressional intent, and that Congress' purpose is the ‘ultimate touchstone.’ ” Brandner v. UNUM Life Ins. Co. of America, 152 F.Supp.2d 1219, 1223 (D.Nev.2001).

However, the Supreme Court has also “instructed that there is a presumption against holding that ERISA preempts state or local laws regulating matters that fall within the traditional police powers of the State.” Golden Gate Restaurant v. City and County of S.F., 512 F.3d 1112, 1120 (9th Cir.2008). Traditionally, such powers include the regulation of health and safety matters. De Buono v. NYSA–ILA Medical and Clinical Services Fund, 520 U.S. 806, 814, 117 S.Ct. 1747, 138 L.Ed.2d 21 (1997). “[N]othing in the language of [ERISA] or the context of its passage indicates that Congress chose to displace general health care regulation, which historically has been a matter of local concern.” New York State Conference of Blue Cross & Blue Shield Plans v. Travelers Ins. Co., 514 U.S. 645, 661, 115 S.Ct. 1671, 131 L.Ed.2d 695 (1995).

ERISA section 514(a) expressly “preempts all state laws that ‘relate to’ any employee benefit plan”; however, laws regulating insurance, banking, or securities are exempt. 29 U.S.C. § 1144(a); Cervantes v. Health Plan of Nevada, 127 Nev. ––––, ––––, 263 P.3d 261, (2011). A law “relates to” a covered employee benefit plan if it has a “reference to” or “connection with” it. California Div. of Labor Standards Enforcement v. Dillingham Constr. N.A. Inc., 519 U.S. 316, 324, 117 S.Ct. 832, 136 L.Ed.2d 791 (1997). We conclude that NRS Chapter 695G does not have a reference to or (under the set of facts alleged before us) a connection with an ERISA plan.

A law has a reference to an employee benefit plan for purposes of ERISA preemption analysis when it “acts immediately and exclusively upon ERISA plans ... or where the existence of ERISA plans is essential to the law's operation.” Id. at 325, 117 S.Ct. 832. This “reference to” prong does not preempt NRS 695G.180 because NRS Chapter 695G's quality assurance requirements apply to all MCOs, regardless of their ERISA status or relationship with any ERISA plan. Cervantes, 127 Nev. at ––––, 263 P.3d at ––––.

A law without a reference to an employee benefit plan may still be preempted if it has a prohibited “connection with” an ERISA plan. Dillingham, 519 U.S. at 325, 117 S.Ct. 832. To determine if a law has such a connection, courts consider the following factors:

(1) whether the state law regulates the types of benefits of ERISA employee welfare benefits plans; (2) whether the state law requires the establishment of a separate employee benefit plan to comply with the law; (3) whether the state law imposes reporting, disclosure, funding, or vesting requirements for ERISA plans; and (4) whether the state law regulates certain ERISA relationships, including the relationships between an ERISA plan and employer and, to the extent an employee benefit plan is involved, between the employer and employee.

Insco, 673 F.Supp.2d at 1187 (quoting Oper. Eng. Health & Welfare v. JWJ Contracting Co., 135 F.3d 671, 678 (9th Cir.1998)). “In evaluating these factors, courts are also to consider the purpose of ERISA, which is to provide a uniform regulatory regime over employee benefit plans.” Insco, 673 F.Supp.2d at 1187 (internal citations omitted).

Administrative decisions

In Cervantes v. Health Plan of Nevada, this court joined the Third, Fifth, Ninth, and Tenth Circuits in holding that ERISA preempts suits that are predicated on administrative decisions made in administering an ERISA plan. 127 Nev. ––––, ––––, 263 P.3d 261, –––– (2011); see Bui v. American Telephone & Telegraph Co. Inc., 310 F.3d 1143, 1147–48 & n. 11 (9th Cir.2002). However, when the conduct at issue “is not performed in the capacity of the ERISA plan, plan administrator, or plan agent, these claims are not preempted by ERISA section 514(a) because the relationship...