Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Sanat V. Sanghani, M.D., LLC 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., et al.

          DRELL CHIEF JUDGE

          REPORT AND RECOMMENDATION

          Joseph H.L. Perez-Montes United States Magistrate Judge

         I. Background

         Before 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”).[1] 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 seq. (“ERISA”).

         Sanghani 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[2] that induced Sanghani to provide services, which United Healthcare apparently did not intend to pay for as agreed.

         United 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.

         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 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)).

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

         United Healthcare contends Sanghani failed to plead or show exhaustion of his 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 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.

         United 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). ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.