United States District Court, W.D. Louisiana, Alexandria Division
SANAT V. SANGHANI, M.D., LLC
UNITED HEALTHCARE SERVICES, INC., et al.
REPORT AND RECOMMENDATION
H.L. Perez-Montes United States Magistrate Judge
the Court is a complaint for payment of healthcare benefits,
pursuant to ERISA and Louisiana state law, filed by Plaintiff
Sanat V. Sanghani, M.D.
(“Sanghani”). The named defendants are The
Associates' Health and Welfare Plan (“The
Plan”), a health and welfare employee benefit plan
sponsored by Wal-Mart Stores, Inc. for the benefit of its
employees; and United Healthcare Services, Inc.
(“United Healthcare”), The Plan administrator.
The Plan was established pursuant to the Employee Retirement
Income Security Act of 1974, 29 U.S.C. § 1001, et
contends he provided healthcare services to a patient
(“S.R.”), which were covered under The Plan.
Sanghani contends that S.R. assigned Sanghani her right to
benefits under The Plan for services rendered. Sanghani
further contends that, although he is not a preferred
provider under The Plan, he had “gap approval”
from United Healthcare. However, United Healthcare ignored
the Gap Approval Agreement and only paid a portion of
Sanghani's bill, deeming him an “out of
network” provider. Sanghani seeks to enforce the
assignment of rights and recover the cost of services, $ 5,
310.82, 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
pursuant to La. C.C. Article 2315, alleging the “gap
approval” process constituted a promise to pay
benefits that induced Sanghani to provide services,
which United Healthcare apparently did not intend to pay for
Healthcare removed the case on the basis of ERISA preemption
and filed a motion to dismiss, which was denied. United
Healthcare filed a second motion to dismiss or for summary
judgment (Doc. 26), alleging that Sanghani failed to exhaust
his administrative remedies under ERISA. 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 that 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 his
administrative remedies pursuant to
Healthcare contends Sanghani failed to plead or show
exhaustion of his 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 his complaint that he filed a claim with United
Healthcare, which 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 he has reviewed United Healthcare's
files related to S.R. and found there was no grievance or
appeal filed by or on behalf of S.R. (Doc. 26-3). United
Healthcare further shows the plan is capable of providing the
relief sought by Sanghani through the “Appeals and
Claims” process (Doc. 26-2). ...