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Sanghani v. United Healthcare Services, Inc.

United States District Court, W.D. Louisiana, Alexandria Division

March 6, 2017

SANAT V. SANGHANI, M.D., LLC
v.
UNITED HEALTHCARE SERVICES, INC.

          DRELL CHIEF JUDGE.

          REPORT AND RECOMMENDATION

          JOSEPH H.L. PEREZ-MONTES UNITED STATES MAGISTRATE JUDGE.

         I. Background

         Before the Court is a complaint filed to recover healthcare benefits pursuant to La. R.S. 22:1821 by Plaintiff Sanat V. Sanghani, M.D. (“Sanghani”) in the Louisiana Ninth Judicial District Court. The named defendants are McDermott Investments, LLC, Choice Plus Basic Plan (“The Plan”), a health and welfare employee benefit plan sponsored by MdDermott Investments, LLC (“MDI”) for the benefit of its employees, and administered by United Healthcare Services, Inc. (“United Healthcare”) (Doc. 22). The Plan is a self-funded employee health and welfare benefit plan that was established pursuant to the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001, et seq. (“ERISA”).

         Sanghani contends she provided healthcare services to a patient, Shelby McGuire, which were covered under The Plan. Sanghani contends that McGuire assigned his rights to benefits under The Plan to her to pay for services rendered (Doc. 1). Sanghani further contends that, although she is not a preferred provider under The Plan, she had Gap Approval from United Healthcare. However, when it was time to pay her, United Healthcare ignored the Gap Approval Agreement and only paid a lower portion of Sanghani's bill, deeming her an “out of network” provider. Sanghani seeks to enforce the assignment of rights and recover the cost of services, $ 8, 918.91, with unpaid benefits due under the plan, as well as penalties, attorney fees, interest, and costs. In the alternative, Sanghani seeks recovery from United Healthcare under La.C.C. art. 2315, for it's “gap approval” process that constituted a promise to pay benefits[1] and induced Sanghani to provide services that United Healthcare did not intend to pay for.

         United Healthcare removed the case to this Court on the basis of ERISA preemption and filed a motion to dismiss (Doc. 10) that was denied. United Healthcare filed a second motion to dismiss or for summary judgment (Doc. 26) alleging that Sanghani failed to exhaust her administrative remedies under ERISA and failed to state a claim on which relief can be granted. That motion is now before the Court for disposition.

         II. Law and Analysis

         A. Standards governing the Motion to Dismiss pursuant to 12(b)(6).

         A motion to dismiss an action pursuant to Fed.R.Civ.P. Rule 12(b)(6), for failure to state a claim admits the facts alleged in the complaint, but challenges the plaintiff's right to relief based upon those facts. See Crowe v. Henry, 43 F.3d 198, 203 (5th Cir. 1995). In particular, a complaint should not be dismissed for failure to state a claim unless it appears beyond a doubt that the plaintiff can prove no set of facts in support of his claim which would entitle him to relief. See Hirras v. National Railroad Passenger Corp., 10 F.3d 1142, 1144 (5th Cir. 1994), vacated on other grounds, 512 U.S. 1231 (1994); Doe, 753 F.2d at 1102. The factual allegations of the complaint must be taken as true, and any ambiguities must be resolved in favor of the pleader. See Doe v. U.S. Dept. of Justice, 753 F.2d 1092, 1101 (D.C.Cir. 1985). The Court must presume that general allegations embrace the specific facts that are necessary to support the claim. See National Organization for Women, Inc. v. Scheidler, 510 U.S. 249 (1994) (citing Lujan v. Defenders of Wildlife, 504 U.S. 555 (1992)).

         B. Sanghani failed to plead or show exhaustion of her administrative remedies pursuant to ERISA.

         United Healthcare contends Sanghani failed to plead or show exhaustion of her administrative remedies pursuant to ERISA.

         Claimants seeking benefits from an ERISA plan must first exhaust available administrative remedies under the plan before bringing suit to recover benefits. In the ERISA context, the exhaustion requirement is jurisprudentially mandated. See Denton v. First National Bank of Waco, 765 F.2d 1295, 1297 (5th Cir. 1985), and is not a prerequisite to a federal court's jurisdiction. Hager v. Nationsbank, 167 F.3d 245, 248 n. 3 (5th Cir. 1999). A plaintiff must exhaust administrative remedies where the grievance upon which the lawsuit is based arises from some action of a plan covered by ERISA, and the plan is capable of providing the relief sought by the plaintiff. See Chailland v. Brown & Root, Inc., 45 F.3d 947, 950 (5th Cir. 1995); see also Wilson v. Kimberly-Clark Corp., 254 Fed.Appx. 280, 285 (5th Cir. 2007). In the Fifth Circuit, ERISA exhaustion is an affirmative defense. See Crowell v. Shell Oil Co., 541 F.3d 295, 308-09 & n.57 (5th Cir. 2008); Wilson, 254 Fed.Appx. at 286. A complaint alleging an ERISA claim is therefore not subject to dismissal under Rule 12(b)(6) because it fails to allege facts disproving a possible affirmative defense of exhaustion. See Wilson, 254 Fed.Appx. at 287.

         Sanghani states in her complaint that she gave made a claim to United Healthcare that was rejected. Sanghani does not allege any further efforts to collect from United Healthcare.

         United Healthcare shows, in an affidavit by Jane Stalinski, a “Legal Case Information Analyst” for United Healthcare, that she has reviewed United Healthcare's files related to Shelby and found there was no grievance or appeal filed by or on behalf of Shelby (Doc. 26-4). United Healthcare further shows the plan is capable of providing the relief sought by Sanghani through the “Appeals and Claims” process (Doc. 26-3). ...


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