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Cardiovascular Specialty Care Center of Baton Rouge, LLC v. United Healthcare of Louisiana, Inc.

United States District Court, M.D. Louisiana

June 1, 2017

CARDIOVASCULAR SPECIALTY CARE CENTER OF BATON ROUGE, LLC
v.
UNITED HEALTHCARE OF LOUISIANA, INC.

          RULING AND ORDER

          BRIAN A. JACKSON, CHIEF JUDGE UNITED STATES DISTRICT COURT.

         Before 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. 18.[1] 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.[2] For the reasons explained herein, Defendant's Motion for Summary Judgment on Counts V and VI of Plaintiffs Second Amended Complaint (Doc. 99) is GRANTED.

         I. BACKGROUND

         Plaintiff 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 by Defendant.

         The procedure that Plaintiff utilized to communicate with Defendant before performing a procedure on a patient who was insured by Defendant is undisputed.[3]Before rendering medical services to a patient, Plaintiff generally would contact a representative of Defendant by telephone.[4] 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.[5] In return, Defendant would communicate to Plaintiff a determination of medical necessity for purposes of coverage under each patient's insurance plan.[6] 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.[7] 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 services rendered.[8]

         Plaintiff also required all patients relevant to this suit to sign a "Release of Information Form."[9] 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."[10]

         After 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.

         II. LEGAL STANDARD

         Summary 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. Fed.R.Civ.P. 56(c)(1).

         "[W]hen 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).

         In sum, 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).

         III. DISCUSSION

         Defendant 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.[11] 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 ...


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