United States District Court, W.D. Louisiana, Alexandria Division
SANAT V. SANGHANI, M.D., LLC
UNITED HEALTHCARE SERVICES, INC.
REPORT AND RECOMMENDATION
H.L. PEREZ-MONTES UNITED STATES MAGISTRATE JUDGE.
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”).
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 and induced Sanghani to provide services
that United Healthcare did not intend to pay for.
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.
Law and Analysis
Standards governing the Motion to Dismiss pursuant to
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)).
Sanghani failed to plead or show exhaustion of her
administrative remedies pursuant to
Healthcare contends Sanghani failed to plead or show
exhaustion of her administrative remedies pursuant to ERISA.
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.
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.
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). ...