United States District Court, M.D. Louisiana
RULING AND ORDER
A. JACKSON, CHIEF JUDGE UNITED STATES DISTRICT COURT.
the Court is the Motion for Summary Judgment on Counts V and
VI of Plaintiffs Second Amended Complaint (Doc. 99) filed by
Defendant United Healthcare of Louisiana, Inc. Defendant
seeks summary judgment on Plaintiffs remaining claims, in
which Plaintiff asserts theories of detrimental reliance,
see La. Civ. Code art. 1967, and the failure to pay
benefits pursuant to the Employee Retirement Income Security
Act of 1974 ("ERISA"), 29 U.S.C. ch.
Plaintiff filed a memorandum in opposition to the Motion,
(see Doc. 108), and Defendant filed a reply to
Plaintiffs memorandum in opposition, (see Doc. 114).
On March 17, 2017, the Court held oral argument on the
Motion. For the reasons explained herein,
Defendant's Motion for Summary Judgment on Counts V and
VI of Plaintiffs Second Amended Complaint (Doc. 99) is
Cardiovascular Specialty Care Center of Baton Rouge, LLC -
which provides cardiovascular services to patients in Baton
Rouge, Louisiana - initiated this lawsuit to collect pajinent
from Defendant United Healthcare of Louisiana, Inc., for
services that Plaintiff rendered to patients who were insured
procedure that Plaintiff utilized to communicate with
Defendant before performing a procedure on a patient who was
insured by Defendant is undisputed.Before rendering medical
services to a patient, Plaintiff generally would contact a
representative of Defendant by telephone. During such a
telephone call, Plaintiff would provide information to
Defendant regarding the diagnosis of a patient and the
medical necessity of the proposed services. In return,
Defendant would communicate to Plaintiff a determination of
medical necessity for purposes of coverage under each
patient's insurance plan. Following this telephone call,
Plaintiff then would access an online portal that is
maintained by Defendant, in which Plaintiff could access
information such as the deductibles and co-insurance amounts
associated with the patient's insurance
plan. Plaintiff then would record the
information obtained through this process, which generally
consisted of the patient's in-network and out-of-network
deductibles and the maximum amount of expenses that a patient
would be required to pay out-of-pocket for any medical
also required all patients relevant to this suit to sign a
"Release of Information Form." By signing this
document, all patients executed an assignment in favor of
Plaintiff, which stated, "I authorize and request my
insurance company to pay directly to the doctor the amount
due to me in my pending claim for Medical or Surgical
treatment or services, by reason of such treatment or
services rendered to me."
Defendant allegedly failed to pay claims submitted by
Plaintiff to its satisfaction, Plaintiff brought this
lawsuit, claiming - among other grounds - that it had relied,
to its detriment, on representations made by Defendant that
it would pay the claims and that Defendant had failed to pay
benefits pursuant to ERISA.
judgment is appropriate "if the movant shows that there
is no genuine dispute as to any material fact and the movant
is entitled to judgment as a matter of law."
Fed.R.Civ.P. 56(a). "A party asserting that a fact
cannot be or is genuinely disputed must support the assertion
by . . . citing to particular parts of materials in the
record [-] including depositions, documents, electronically
stored information, affidavits or declarations, stipulations
(including those made for purposes of the motion only),
admissions, [and] interrogatory answers" - or by
averring that an adverse party cannot produce admissible
evidence to support the presence of a genuine dispute.
a properly supported motion for summary judgment is made, the
adverse party must set forth specific facts showing that
there is a genuine issue for trial." Anderson v.
Liberty Lobby, Inc., 477 U.S. 242, 250 (1986) (quotation
marks and footnote omitted). "This burden is not
satisfied with some metaphysical doubt as to the material
facts, by conclusory allegations, by unsubstantiated
assertions, or by only a scintilla of evidence."
Little v. Liquid Air Corp., 37 F.3d 1069, 1075 (5th
Cir. 1994) (quotation marks and citations omitted). In
determining whether the movant is entitled to summary
judgment, the Court "view[s] facts in the light most
favorable to the non-movant and draw[s] all reasonable
inferences in her favor." Coleman v. Hous. Indep.
Sch. Dist., 113 F.3d 528, 533 (5th Cir. 1997).
summary judgment is appropriate if, "after adequate time
for discovery and upon motion, [the non-movant] fails to make
a showing sufficient to establish the existence of an element
essential to that party's case, and on which that party
will bear the burden of proof at trial." Celotex
Corp. v. Catrett, 477 U.S. 317, 322 (1986).
asserts that it is entitled to summary judgment on Plaintiffs
detrimental reliance claim, arguing that it never represented
to Plaintiff that any of the procedures it performed on
patients would be covered under those patients' plans or
that Defendant would pay a certain amount for those
procedures. Defendant additionally asserts that it
nonetheless was unreasonable for Plaintiff to rely on
information regarding the medical necessity of a procedure
and a patient's level of benefits to assume that
Defendant would pay Plaintiff a certain amount for a
particular procedure. Defendant also argues that it is
entitled to summary judgment on Plaintiffs claim pursuant to
ERISA for Defendant's alleged failure to pay benefits
because Plaintiff does not have standing to pursue such a
claim. Because Defendant never engaged in
conduct that can be construed as a "representation"
that Plaintiff would be paid a certain amount for the
services it rendered ...