Rojas v. Cigna Health & Life Ins. Co.

• Decision Date: 15 July 2015
• Docket Number: Docket No. 14–3455.
• Citation: 793 F.3d 253
• Parties: Henry L. ROJAS, M.D., Mitchell K. Rosen, M.D., H & L Rojas, M.D., P.C., dba Rojas and Rosen M.D., Plaintiffs–Counter–Defendants–Appellants, v. CIGNA HEALTH AND LIFE INSURANCE COMPANY, Connecticut General Life Insurance Company, Defendants–Counter–Claimants–Appellees.
• Court: U.S. Court of Appeals — Second Circuit

793 F.3d 253

Henry L. ROJAS, M.D., Mitchell K. Rosen, M.D., H & L Rojas, M.D., P.C., dba Rojas and Rosen M.D., Plaintiffs–Counter–Defendants–Appellants

v.CIGNA HEALTH AND LIFE INSURANCE COMPANY, Connecticut General Life Insurance Company, Defendants–Counter–Claimants–Appellees.^*

Docket No. 14–3455.

United States Court of Appeals, Second Circuit.

Argued: June 1, 2015.

Decided: July 15, 2015.

Richard J. Quadrino (Eugene S.R. Pagano, Harold J. Levy, on the brief), Quadrino Law Group, P.C., Melville, N.Y., for Plaintiffs–Counter–Defendants–Appellants.

Andrew Levchuk (Jodi Kim Miller, on the brief), Bulkley, Richardson and Gelinas, LLP, Springfield, MA, for Defendants–Counter–Claimants–Appellees.

Before: WESLEY and LOHIER, Circuit Judges.^†

Opinion

WESLEY, Circuit Judge:

The issue in this appeal is whether doctors, as healthcare providers, are beneficiaries of their patients' health-insurance plans such that they have standing to seek relief under Section 502 of the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1132(a)(1)(B). Under the circumstances of this case, they are not.

BACKGROUND

Henry L. Rojas and Mitchell K. Rosen are physicians licensed in the State of New York and are co-owners of H & L Rojas, M.D., P.C. (collectively, “Rojas”). Rojas is an in-network healthcare provider with Cigna Health and Life Insurance Company and Connecticut General Life Insurance Company (collectively, “Cigna”). Cigna insureds use Cigna's coverage to pay their bills when they receive medical services from Rojas; in exchange, Rojas accepts reduced reimbursement rates.

Cigna's Benefit Plan covering its insureds states that “All Medical Benefits are payable to you [the patient]. However, at the option of [Cigna], all or any part of them may be paid directly to the person or institution on whose charge [the] claim is based.... When benefits are paid to you or your Dependent, you or your Dependent is responsible for reimbursing the Provider.” J.A. 81.¹

Rojas's Cigna-insured patients assign to Rojas their right to collect payment for medical services directly from Cigna. According to the Complaint, the form signed by Rojas's patients states, in relevant part, as follows:

Assignment and Release : I, the undersigned, have insurance coverage with _________________________ and assign directly to Rojas and Rosen, MD, PC all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, including those related to physical examinations, whether or not paid by insurance.

J.A. 14. Cigna regularly investigates its in-network physicians regarding reimbursement claims that may be inconsistent with Cigna's coverage regarding medical necessity. After an investigation involving Rojas and other practices, Cigna suspected that Rojas was ordering blood tests to measure allergies, instead of skin tests as typically required by Cigna's coverage. Cigna also “noted the frequency by which Dr. Rose[n] and Dr. Rojas submitted claims for blood tests for suspected allergies for each patient.” J.A. 223. Rojas billed a blood panel test “repetitively for the same patient over a sustained period of time,” which is inconsistent with normal allergy testing

practice. J.A. 224.

Cigna expressed its concerns about the allergy tests in a letter from its national medical director for fraud and abuse; that letter initiated a letter exchange between Rojas and Cigna regarding the medical necessity of the allergy tests. Cigna determined that it had overpaid Rojas in the amount of $844,334.52 for allergy tests for about 150 patients and requested that Rojas return the full amount “for the claims paid in error.” J.A. 130. That is when the lawyers got involved. Rojas's attorney objected to Cigna's demand. Cigna's attorney offered to arbitrate the dispute under the parties' provider agreement, but Rojas rejected the offer. Cigna's counsel then notified Rojas that Cigna would terminate Rojas as a healthcare provider in its network.

Rojas filed suit in the United States District Court for the Southern District of New York (Kenneth M. Karas, Judge) seeking, among other things, an injunction “prohibiting all retaliatory acts against [Rojas] including [the] termination of the provider agreements.” J.A. 31. Rojas contended that Cigna had violated the anti-retaliation provision of ERISA, which makes it unlawful for “any person to ... discriminate against a participant or beneficiary for exercising any right to which he is entitled under the provisions of an employee benefit plan.”29 U.S.C. § 1140. Rojas's claim was for reinstatement as a provider, not for payment under the Benefit Plan. Rojas moved for a temporary restraining order and preliminary injunction to prohibit Cigna from terminating Rojas from its provider network. The district court denied Rojas's motion for a preliminary injunction, finding that Rojas lacked standing to bring an ERISA action. The district court noted that, under ERISA, a civil anti-retaliation action may be brought only by a “participant, beneficiary, or fiduciary” of an ERISA plan, see Spec.App. 77 (quoting 29 U.S.C. § 1132(a)(3) ); the court found that Rojas was not a plan “beneficiary” under ERISA. The court held that “Healthcare providers, such as Plaintiffs ... don't become beneficiaries solely by virtue of receiving reimbursement from a plan administrator, such as Cigna.” Spec.App. 78. The district court also determined that while Rojas claimed to have taken assignments of the rights of plan participants, the language of the assignments was limited to receiving reimbursements, and did not convey the right to assert ERISA anti-retaliation claims.

DISCUSSION

We review “statutory standing de novo, provided the statutory standing questions are of a legal nature.” Kendall v. Emps. Ret. Plan of Avon Prods., 561 F.3d 112, 118 (2d Cir.2009).

Section 502(a)(1)(B) of ERISA, codified in Title 29 of the United States Code, provides a federal cause of action for civil claims aimed at enforcing the provisions of an ERISA plan. See 29 U.S.C. § 1132. ERISA enumerates “[p]ersons empowered to bring a civil 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.” Id. § 1132(a)(1)(B). As relevant here, Section 502 is narrowly construed to authorize only two categories of persons to sue directly to enforce their rights under the plan: participants and beneficiaries. Id. § 1132(a)(1) ; see Franchise Tax Bd. of the State of Cal. v. Constr. Laborers Vacation Trust for S. Cal., 463 U.S. 1, 27, 103 S.Ct. 2841, 77 L.Ed.2d 420 (1983) ; see also Chemung Canal Trust Co. v. Sovran Bank/Md., 939 F.2d 12, 14 (2d Cir.1991) (“[I]n the absence of some indication of legislative intent to grant additional parties standing to sue, the list in § 502 should be viewed as exclusive.”).² ERISA defines “participant” as “any employee or former employee of an employer, or any member or former member of an employee organization,” 29 U.S.C. § 1002(7), see also Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 117, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989), and “beneficiary” as “a person designated by a participant, or by the terms of an employee benefit plan, who is or may become entitled to a benefit thereunder,” 29 U.S.C. § 1002(8).

Rojas argues that it has standing. Rojas contends that because it is entitled to reimbursement from Cigna—a literal “benefit”—it is a “beneficiary” entitled to bring claims under Section 502. Rojas claims that its entitlement to receive “benefits” under the Plan is premised on two theories. One, Rojas presses that it is a “plan-designated beneficiary” by virtue of how the Benefit Plan structures payment. Appellants' Br. 36. Rojas points to a section of the Benefit Plan that provides that Cigna may pay Rojas directly for reimbursement for covered services. Thus, Rojas contends, it is a beneficiary under the terms of the Benefit Plan. In the alternative, Rojas argues that it is a “participant-designated beneficiary” because its patients assigned to Rojas their right to payment. Appellants' Br. 36–43. Under both theories, Rojas equates beneficiary status as understood under the statute with the right to receive a “benefit” provided by the healthcare plan. Rojas draws no distinction between its patients' right to have their medical bills paid by Cigna and its right to receive those payments. Neither of these bases for standing is persuasive.

The core of Rojas's claim is that it wants to be reinstated as a Cigna participating provider.³ Rojas has sued under the wrong agreement.⁴ Approved provider status in Cigna's network is a function of Rojas's provider contract with Cigna. When we pointed this out to its counsel at oral argument, Rojas continued to press the claim that it is a beneficiary under ERISA and can sue under the Benefit Plan.⁵ So be it. The district court wisely rejected this argument and found that Rojas is not a beneficiary as defined by ERISA and that its rights, if any, are limited by the assignments made by its patients.

“Beneficiary,” as it is used in ERISA, does not without more encompass healthcare providers. Although the term “benefit” is not defined in ERISA, we are persuaded that Congress did not intend to include doctors in the category of “beneficiaries.” Benefits to which a beneficiary is entitled are bargained-for goods, such as “medical, surgical, or hospital care,” Kolasinski v. Cigna Healthplan of CT, Inc., 163 F.3d 148, 149 n. 1 (2d Cir.1998) (quoting 29 U.S.C. § 1002(1)(A) ), rather than a right to payment for medical services rendered. A beneficiary is best understood as an individual who enjoys rights equal to the participant's to receive coverage from the healthcare plan. A participant's spouse or child is the most likely candidate for this term.⁶ Cameron Manor, Inc. v. United Mine Workers of Am., 575 F.Supp. 1243, 1245 (W.D.P...