Summary
The Eleventh Circuit affirmed dismissal of a pro se healthcare provider’s ERISA claims against Habitat for Humanity International. The court held that the provider lacked a cause of action under ERISA because the plan contained an unambiguous and enforceable anti-assignment provision, rendering the patient’s assignment of benefits void. The court also rejected arguments based on equitable estoppel and waiver and held that amendment would be futile.
Topics
Practice areas
Questions Presented
- Whether an out-of-network healthcare provider may sue under ERISA based on a patient's assignment of benefits when the plan contains an unambiguous anti-assignment provision.
- Whether the alleged failure to disclose the anti-assignment provision supported equitable estoppel or waiver.
- Whether the district court properly denied leave to amend because the proposed amendment would be futile.
- Whether the complaint stated a claim under ERISA section 502(a).
Holdings
- A healthcare provider may acquire derivative standing to sue under ERISA through a written assignment from a participant or beneficiary, but an unambiguous and enforceable anti-assignment provision renders the assignment void and prevents the provider from acquiring a cause of action under section 502(a).
- O.C.G.A. § 33-24-54 does not require an insured to assign benefits to a healthcare provider and does not prohibit an ERISA plan from barring assignments; therefore, the statute did not invalidate the plan's anti-assignment provision.
- Equitable estoppel did not apply because the anti-assignment provision was unambiguous and Griffin did not identify a representation constituting an informal interpretation of an ambiguity.
- Even assuming waiver principles may apply in the ERISA context, Griffin failed to plead facts showing that Habitat voluntarily and intentionally relinquished its known right to enforce the anti-assignment provision.
- The complaint failed to state a claim under ERISA section 502(a) because Griffin lacked a valid assignment and therefore lacked a cause of action under the statute.
- The district court properly denied leave to amend because the proposed additional ERISA claim would have been futile in light of the enforceable anti-assignment provision.
Key quotations
“Although courts have long applied the label of “statutory standing” to the basis for decisions such as the district court’s here, that Dr. Griffin lacked standing under ERISA, the Supreme Court has cautioned that this label is “misleading” because the court is not deciding whether there is subject matter jurisdiction but rather whether the plaintiff “has a cause of action under the statute.”” (641 F. App'x at 930)
“To survive a motion to dismiss, a complaint must contain sufficient factual matter, accepted as true, to “state a claim to relief that is plausible on its face.”” (641 F. App'x at 930)
“Accordingly, when a plan contains an unambiguous anti-assignment provision, a plan participant or beneficiary may not assign benefits to a healthcare provider, meaning the healthcare provider cannot acquire a cause of action under section 502(a).” (641 F. App'x at 931)
Factual background
Dr. Griffin, an out-of-network dermatologist, treated a patient covered by Habitat's self-funded ERISA health plan and alleged that the plan's claims administrator underpaid her claim. The patient executed a written assignment of medical benefits and related ERISA review rights to Griffin, but the plan contained an unambiguous anti-assignment provision. After the claims administrator denied her first administrative appeal and failed to respond to her second appeal or provide requested documents, Griffin sued Habitat under ERISA and related theories.
Procedural history
Dr. Griffin, an out-of-network healthcare provider, sued Habitat under ERISA for unpaid benefits, breach of fiduciary duty, failure to provide plan documents, breach of contract, and related relief. The district court dismissed the complaint without prejudice for lack of statutory standing based on the plan's anti-assignment provision and denied leave to amend as futile. The Eleventh Circuit affirmed.