Memorial Hermann Health System v. Southwest LTC, L ( 2017 )

Case: 16-20477 Document: 00513926759 Page: 1 Date Filed: 03/27/2017
IN THE UNITED STATES COURT OF APPEALS
FOR THE FIFTH CIRCUIT
United States Court of Appeals
Fifth Circuit
No. 16-20477 FILED
Summary Calendar March 27, 2017
Lyle W. Cayce
Clerk
MEMORIAL HERMANN HEALTH SYSTEM,
Plaintiff - Appellant
v.
SOUTHWEST LTC, LIMITED EMPLOYEE BENEFITS PLAN;
SOUTHWEST LTC, LIMITED,
Defendants - Appellees
Appeal from the United States District Court
for the Southern District of Texas
USDC No. 4:14-CV-2572
Before JOLLY, SOUTHWICK, and HIGGINSON, Circuit Judges.
PER CURIAM:*
Memorial Hermann Health System sued Southwest LTC seeking
payment for medical bills incurred by a patient covered by a Southwest health
benefits plan. The district court granted summary judgment in favor of
Southwest, concluding that Memorial failed to exhaust administrative
remedies. Memorial appealed. We AFFIRM.
* Pursuant to 5TH CIR. R. 47.5, the court has determined that this opinion should not
be published and is not precedent except under the limited circumstances set forth in 5TH
CIR. R. 47.5.4.
Case: 16-20477 Document: 00513926759 Page: 2 Date Filed: 03/27/2017
No. 16-20477
The patient, C.W., was covered by an ERISA-governed employee health
benefits plan managed by Southwest. Meritain was the third-party claims
administrator. From June to August 2012, C.W. incurred over $400,000 in
medical bills as a patient at Memorial Hermann Hospital in Houston, Texas.
According to Memorial, C.W. assigned her insurance benefits to Memorial, who
then sought to collect from Meritain.
Memorial and Meritain exchanged multiple letters between October
2012 and June 2013. In them, Meritain repeatedly informed Memorial that it
needed an authorization from C.W. before it could provide documents relating
to C.W. and before Memorial could invoke the administrative process.
Memorial never provided an authorization. Therefore, Meritain did not release
the requested documents. Memorial filed suit against Southwest in state
court. Southwest removed the case to the United States District Court for the
Southern District of Texas based on federal-question jurisdiction. It then filed
a motion for summary judgment, attaching various affidavits and the letters
exchanged between Meritain and Memorial. The district court granted the
motion, concluding that Memorial failed to exhaust administrative remedies.
We review de novo a grant of summary judgment. Swanson v. Hearst
Corp. Long Term Disability Plan, 586 F.3d 1016, 1018 (5th Cir. 2009).
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). “No genuine issue of material fact
exists if the evidence is such that no reasonable juror could find for the
nonmovant.” Swanson, 586 F.3d at 1018.
Memorial seeks benefits under 29 U.S.C. § 1132(a)(1)(B), which permits
a plan participant or beneficiary to recover benefits due under the plan. To
recover, though, Memorial must have exhausted its available administrative
remedies. See Swanson, 586 F.3d at 1019.
2
Case: 16-20477 Document: 00513926759 Page: 3 Date Filed: 03/27/2017
No. 16-20477
Administrative exhaustion is explained in Southwest’s Plan. It provides:
“No action at law or in equity can be brought to recover on this Plan until the
appeals procedure has been exhausted as described in this Plan.” Exhaustion
requires that a “Covered Person,” 1 which includes C.W., “file[] a claim for
benefits in accordance with the terms of the Plan specific to each type of
claim[.]” Meritain insisted that Memorial show it was acting on behalf of C.W.
The Plan provides that it is the employee who has the responsibility “to make
certain each [claim] submitted by h[er] or on h[er] behalf includes all
information necessary to process the claim[.]” If benefits are denied, the appeal
also needed to be brought by the “Covered Person.” Also relevant, Southwest
LTC as the Plan Administrator has the exclusive authority to “interpret the
Plan” and to “determine all questions arising in the administration,
interpretation, and application of the Plan.”
Memorial argues: (1) it provided evidence of exhaustion; (2) even if it did
not actually exhaust its remedies, it should be deemed to have exhausted them;
and (3) it should be excused from the exhaustion requirement because it was
denied “meaningful access” to administrative remedies. Key to the district
court’s rejection of each argument was that Memorial failed to provide
Meritain with an authorization from C.W. to evidence that Memorial was a
“Covered Person.”
We agree with the district court. True, “an assignee of a plan participant
has derivative standing to bring a cause of action for enforcement under
ERISA.” Tango Transp. v. Healthcare Fin. Servs. LLC, 322 F.3d 888, 892 (5th
Cir. 2003). For whatever reason, though, Memorial failed to provide Meritain
with proof of an authorization or assignment from C.W. Consequently,
1 The Plan defines “Covered Person” as “any Employee or Dependent who has met the
eligibility requirements of the . . . Plan while such person is covered hereunder.”
3
Case: 16-20477 Document: 00513926759 Page: 4 Date Filed: 03/27/2017
No. 16-20477
Memorial did not exhaust administrative remedies. We also see no basis to
conclude that Meritain was denied meaningful access to the administrative
process. When the Plan Administrator is clearly advising a would-be claimant
of a valid task it must perform so that a claim may be processed, there is no
interference with access. McGowin v. ManPower Int’l, Inc., 363 F.3d 556, 560
(5th Cir. 2004).
AFFIRMED.
4