the United Healthcare Choice Plus Plan for City of Austin Employees and the City of Austin v. Charles Lesniak ( 2015 )

ACCEPTED
03-15-00309-CV
5802501
THIRD COURT OF APPEALS
AUSTIN, TEXAS
6/24/2015 11:26:16 AM
JEFFREY D. KYLE
CLERK
NO. 03-15-00309-CV
CITY OF AUSTIN and THE UNITED § IN THE THIRD FILED IN
3rd COURT OF APPEALS
HEALTHCARE CHOICE PLUS PLAN § AUSTIN, TEXAS
FOR CITY OF AUSTIN EMPLOYEES, § 6/24/2015 11:26:16 AM
§ JEFFREY D. KYLE
Appellants, § COURT OF APPEALS Clerk
IN
v. §
§
CHARLES LESNIAK, §
§
Appellee. § AUSTIN, TEXAS
JOINT APPELLANTS’ BRIEF
ORAL ARGUMENT IS REQUESTED
Andrew G. Jubinsky Andralee Cain Lloyd
Texas Bar No. 11043000 State Bar No. 24071577
andy.jubinsky@figdav.com andralee.lloyd@austintexas.gov
Lance V. Clack Megan Mosby
Texas Bar No. 24040694 State Bar No. 24073392
lance.clack@figdav.com megan.mosby@austintexas.gov
FIGARI + DAVENPORT, LLP CITY OF AUSTIN – LAW DEPARTMENT
901 Main Street, Suite 3400 P. O. Box 1546
Dallas, Texas 75202 Austin, Texas 78767-1546
(214) 939-2000 (512) 974-2918
(214) 939-2090 (Fax) (512) 974-1311 (Fax)
ATTORNEYS FOR APPELLANT ATTORNEYS FOR APPELLANT
THE UNITED HEALTHCARE CHOICE PLUS CITY OF AUSTIN
PLAN FOR CITY OF AUSTIN EMPLOYEES
IDENTITY OF PARTIES AND COUNSEL
Appellant Trial and Appellate Counsel
The United Healthcare Choice Plus Andrew G. Jubinsky
Plan for City of Austin Employees Texas Bar No. 11043000
andy.jubinsky@figdav.com
Lance V. Clack
Texas Bar No. 24040694
lance.clack@figdav.com
FIGARI + DAVENPORT, LLP
901 Main Street, Suite 3400
Dallas, Texas 75202
(214) 939-2000
Appellant Trial and Appellate Counsel
The City of Austin Andralee Cain Lloyd
State Bar No. 24071577
andralee.lloyd@austintexas.gov
Megan Mosby
State Bar No. 24073392
megan.mosby@austintexas.gov
CITY OF AUSTIN – LAW DEPARTMENT
P. O. Box 1546
Austin, Texas 78767-1546
(512) 974-2918
Appellee Trial and Appellate Counsel
Charles Lesniak Amar Raval
araval@plummerlawyers.com
James C. Plummer
jplummer@plummerlawyers.com
PLUMMER & KUYKENDALL
4203 Montrose Blvd., Suite 270
Houston, Texas 77006
(713) 522-2887
-i-
TABLE OF CONTENTS
TABLE OF CONTENTS .......................................................................................... ii
INDEX OF AUTHORITIES.....................................................................................iv
STATEMENT OF THE CASE .................................................................................. 1
APPELLANTS’ STATEMENT REGARDING ORAL ARGUMENT .................... 1
ISSUE PRESENTED .................................................................................................1
1. Whether the Trial Court erred in denying Appellants’ plea
to the jurisdiction. ......................................................................................................1
STATEMENT OF FACTS ........................................................................................2
A. The Plan. ..........................................................................................2
B. Appellee’s Claims. ................................................................................3
SUMMARY OF ARGUMENT .................................................................................4
ARGUMENT .............................................................................................................5
A. Standard of Review on Appeal.............................................................. 5
B. Governmental Immunity. ...................................................................... 5
C. The Plan is Immune From Suit and Liability. ....................................... 7
D. Appellee Has Not Pled a Valid Waiver of Immunity. .......................... 8
1. The Proprietary/Governmental Function Distinction Does
Not Apply. ...................................................................................8
2. Appellee did not plead a valid waiver of immunity under
Chapter 271. ..............................................................................10
PRAYER ..................................................................................................................10
-ii-
CERTIFICATE OF COMPLIANCE ................................................................................ 12
CERTIFICATE OF SERVICE .......................................................................................... 12
APPENDIX
-iii-
INDEX OF AUTHORITIES
Page(s)
CASES
Anderson v. City of San Antonio,
120 S.W.3d 5 (Tex. App.—San Antonio 2003, pet. denied) .................................. 5
Ben Bolt-Palito Blanco Consol. Indep. Sch. Dist. v. Texas Political
Subdivisions Prop./Cas. Joint Self-Ins. Fund,
212 S.W.3d 320 (Tex. 2006) .................................................................................. 5, 7
City of Georgetown v. Lower Colorado River Authority,
413 S.W.3d 803 (Tex. App.—Austin 2013, pet. dism’d) ....................................... 9
City of San Antonio ex rel. City Pub. Serv. Bd. v. Wheelabrator Air Pollution
Control, Inc.,
381 S.W.597 (Tex. App.—San Antonio 2012, pet. denied) ................................... 8
Dallas County Mental Health and Mental Retardation v. Bossley,
968 S.W.2d 339 (Tex. 1998) ...................................................................................... 5
East Houston Estate Apartments, LLC v. City of Houston,
294 S.W.3d 723 (Tex. App.—Houston [1st Dist.] 2009, no pet.) ....................... 10
Foster v. Teacher Ret. Sys.,
273 S.W.3d 883 (Tex. App.—Austin 2008, no pet.) ............................................... 8
Gay v. City of Wichita Falls,
457 S.W.3d 499 (Tex. App.—El Paso 2014, no pet.) ..................................... 7, 8, 9
General Services Com’n v. Little-Tex Insulation Co., Inc.,
39 S.W.3d 591 (Tex. 2001) ........................................................................................ 6
Gentilello v. University of Texas Southwestern Health Systems,
2014 WL 1225160 (Tex. App.—Dallas, 2014)........................................................ 6
Humana Ins. Co. v. Mueller,
2015 WL 1938657, No. 04-14-752-CV (Tex. App.—San Antonio, April
29, 2015, no pet. h.) ..................................................................................................... 9
Lubbock County Water Control & Imp. Dist. v. Church & Akin, L.L.C.,
442 S.W.3d 297 (Tex. 2014) .................................................................................... 10
-iv-
Mayhew v. Town of Sunnyvale,
964 S.W.2d 922 (Tex.1998) ....................................................................................... 5
Republic Power Partners, L.P. v. City of Lubbock,
424 S.W.3d 184 (Tex. App.—Amarillo 2014, no pet.) ....................................... 8, 9
Richardson Hosp. Auth. v. Duru,
387 S.W.3d 109 (Tex. App.—Dallas 2012, no pet.) ............................................... 7
State v. Lueck,
290 S.W.3d 876 (Tex. 2009) ...................................................................................... 5
Tex. Natural Res. Conservation Comm’n v. IT-Davy,
74 S.W.3d 849 (Tex. 2002) ........................................................................................ 5
Texas Ass’n of Bus. v. Texas Air Control Bd.,
852 S.W.2d 440 (Tex. 1993) ...................................................................................... 6
Texas Dep’t of Parks and Wildlife v. Miranda,
133 S.W.3d 217 (Tex. 2004) .................................................................................. 5, 6
Texas Dept. of Pub. Safety v. Int’l Capital Corp.,
40 S.W.3d 687 (Tex. App.—Austin 2001, no pet.) ................................................. 5
Texas Dept. of Transportation v. Jones,
8 S.W.3d 636 (Tex. 1999) .......................................................................................... 7
Tooke v. City of Mexia,
197 S.W.3d 325 (Tex. 2006) .................................................................................. 5, 7
University of Tex. Med. Branch v. York,
871 S.W.2d 175 (Tex.1994) ....................................................................................... 6
STATUTES
Tex. Civ. Prac. & Rem. Code § 51.014 .......................................................................... 1
Texas Loc. Gov’t Code § 271.151 ............................................................................ 2, 10
Texas Loc. Gov’t Code § 271.152 .............................................................................. 4, 8
Texas Gov’t Code § 2259.001 ................................................................................. 4, 7, 9
-v-
Texas Gov’t Code § 2259.002 ................................................................................. 4, 7, 9
Texas Gov’t Code § 2259.031 ..................................................................................... 2, 7
-vi-
STATEMENT OF THE CASE
This is a suit for benefits under a self-funded health plan established by the
City of Austin for its eligible employees. [C.R. 29-30.] Appellants The United
Healthcare Choice Plus Plan for the City of Austin (the “Plan”) and the City of
Austin (the “City”) filed a joint plea to the jurisdiction based on sovereign
immunity, inasmuch as the City and the Plan are governmental entities. [C.R. 29.]
The Trial Court denied the plea, and Appellants appealed pursuant to Tex. Civ.
Prac. & Rem. Code § 51.014. [C.R. 206-208, 210.]
APPELLANTS’ STATEMENT REGARDING ORAL ARGUMENT
Appellants believe that, given the importance of the issues presented by this
appeal, oral argument would aid the Court’s decision making process.
ISSUE PRESENTED
1. Whether the Trial Court erred in denying Appellants’ plea to the
jurisdiction.
JOINT APPELLANTS’ BRIEF - Page 1
STATEMENT OF FACTS
A. The Plan.
The City of Austin is a local governmental entity as defined by the Local
Gov’t Code § 271.151. The Plan is a self-funded plan solely funded by the City of
Austin and created pursuant to Texas Gov’t Code § 2259.031. [C.R. 30.] The
terms of the Plan are set forth in the “Summary Master Benefit Plan Documents”
(the “SPDs”), effective January 1, 2013, and January 1, 2014. [C.R. 30.]
The Plan provides:
1.1 Purpose
The City has contracted with United HealthCare
Services, Inc. (UnitedHealthcare), a private healthcare
claims administrator, to administer this Plan and process
the payment or reimbursement of specified expenses
incurred by eligible Covered Persons.
***
1.13 Interpretation of Benefits
The Plan Administrator has the sole and exclusive
discretion to do all of the following:
1. Interpret Benefits under the Plan.
2. Interpret the other terms, conditions, limitations,
and exclusions set out in the Plan Document.
3. Make factual determinations related to the Plan
and its Benefits.
4. The Plan Administrator may, in certain
circumstances, for purposes of overall cost savings
or efficiency, in its sole discretion, offer Benefits
JOINT APPELLANTS’ BRIEF - Page 2
for services that would otherwise not be Covered
Services. The fact that the Plan Administrator
does this in any particular case shall not in any
way be deemed to require the Plan Administrator
to do so in similar cases.
[C.R. 93-94.] Further, the Plan sets forth a remedy in the event a claim for benefits
is denied, namely, a member has two levels of appeal: an internal appeal to the
Plan Administrator and, if the first appeal is denied, a second, external appeal to an
Independent Review Organization unaffiliated with the Plan or the City. [C.R. 89-
93.]
B. Appellee’s Claims.
Appellee is an employee of the City of Austin and a qualified member of the Plan.
[C.R. 30.] Appellee’s daughter underwent treatment in 2013 and 2014, and
submitted claims to the Plan related to this treatment. [C.R. 30-31.] The Plan
Administrator denied some of the claims because the services in question were not
medically necessary. [Id.] Appellee appealed through each level provided by the
Plan, and the original denial was upheld. [C.R. 3-5.] Appellee filed suit against
Appellants seeking benefits under the Plan. [C.R. 3.] Appellants filed a joint plea
to the jurisdiction, which the Trial Court denied. [C.R. 29, 206.]
JOINT APPELLANTS’ BRIEF - Page 3
SUMMARY OF ARGUMENT
Appellants have governmental immunity from Appellee’s claims. Absent
legislative waiver, governmental immunity deprives the trial court of jurisdiction to
hear Appellee’s claims, and no such waiver exists. Appellee bears the burden of
pleading a valid waiver of immunity, and he has not done so. Specifically,
Appellee pled that the City was engaged in a proprietary function, however, the
distinction between proprietary and governmental functions on which Appellee
relies has been abolished by Tex. Local Gov’t Code § 271.152, and the legislature
has stated expressly that a municipality does not waive immunity by establishing a
self funded plan. See Tex. Gov’t Code §§ 2259.001, 2259.002. Appellee also
pled, in the alternative, that Appellants waived immunity pursuant to Section
271.152. This argument fails because Appellee is not suing under a contract that
provided services to a governmental entity. This Court should reverse the order of
the Trial Court and dismiss Appellee’s claims with prejudice.
JOINT APPELLANTS’ BRIEF - Page 4
ARGUMENT
A. Standard of Review on Appeal.
A trial court's ruling on a plea to the jurisdiction is reviewed under a de novo
standard of review. Anderson v. City of San Antonio, 120 S.W.3d 5, 7 (Tex.
App.—San Antonio 2003, pet. denied); Texas Dept. of Pub. Safety v. Int’l Capital
Corp., 40 S.W.3d 687, 688 (Tex. App.—Austin 2001, no pet.); Mayhew v. Town of
Sunnyvale, 964 S.W.2d 922, 928 (Tex.1998).
B. Governmental Immunity.
Absent legislative waiver, governmental immunity shields governmental
entities, including municipalities, from suit for common law and statutory claims.
See, e.g., Tooke v. City of Mexia, 197 S.W.3d 325, 332 (Tex. 2006); Ben Bolt-
Palito Blanco Consol. Indep. Sch. Dist. v. Texas Political Subdivisions Prop./Cas.
Joint Self-Ins. Fund, 212 S.W.3d 320, 327 (Tex. 2006) (holding that immunity
extended to self-funded plans or cooperative insurance entities created by
governmental entities); Tex. Natural Res. Conservation Comm’n v. IT-Davy, 74
S.W.3d 849, 853-55 (Tex. 2002); Dallas County Mental Health and Mental
Retardation v. Bossley, 968 S.W.2d 339, 341-42 (Tex. 1998); see also State v.
Lueck, 290 S.W.3d 876, 880 (Tex. 2009). Governmental immunity from suit
deprives the trial court of subject matter jurisdiction and, thus, is properly asserted
in a plea to the jurisdiction. Texas Dep’t of Parks and Wildlife v. Miranda, 133
JOINT APPELLANTS’ BRIEF - Page 5
S.W.3d 217, 225-226 (Tex. 2004). When subject matter jurisdiction is contested,
“[t]he trial court must determine at its earliest opportunity whether it has the
constitutional or statutory authority to decide the case before allowing the litigation
to proceed.” Id. at 226. Whether the trial court has subject matter jurisdiction is a
question of law subject to de novo appeal. Id.
Appellee bears the burden to allege facts that affirmatively demonstrate the
trial court’s jurisdiction to hear a case. Texas Ass’n of Bus. v. Texas Air Control
Bd., 852 S.W.2d 440, 443 (Tex. 1993). If the pleadings affirmatively negate the
existence of jurisdiction, the plea to the jurisdiction may be granted without
allowing the plaintiff an opportunity to amend. Texas Dept. of Parks and Wildlife
v. Miranda, 133 S.W.3d 217, 226, 227 (Tex. 2004).
The State’s consent may be alleged either by reference to a statute or by
pleading express legislative permission. General Services Com’n v. Little-Tex
Insulation Co., Inc., 39 S.W.3d 591, 594 (Tex. 2001). Texas does not recognize the
doctrine of waiver of governmental immunity by conduct. Gentilello v. University
of Texas Southwestern Health Systems, 2014 WL 1225160, at *5 (Tex. App.—
Dallas, 2014) (“In summary, the Texas Supreme Court has never ruled that a
doctrine of waiver of governmental immunity by conduct exists.”). Legislative
consent to sue must be made in “clear and unambiguous language.” University of
Tex. Med. Branch v. York, 871 S.W.2d 175, 177 (Tex.1994). Absent this consent,
JOINT APPELLANTS’ BRIEF - Page 6
the trial court lacks a jurisdictional basis to hear the claim. Texas Dept. of
Transportation v. Jones, 8 S.W.3d 636, 638-39 (Tex. 1999). Here, Appellee failed
to allege a valid waiver of immunity, and the Trial Court therefore erred in denying
Appellants’ plea to the jurisdiction.
C. The Plan is Immune From Suit and Liability.
The City is a governmental entity immune from suit, absent legislative
waiver. See, e.g., Ben Bolt-Palito Blanco Consol. Indep. Sch. Dist. v. Texas
Political Subdivisions Prop./Cas. Joint Self-Ins. Fund, 212 S.W.3d 320, 327 (Tex.
2006). The Plan, as an entity created by the City pursuant to authority granted by
Texas Gov’t Code § 2259.031, is likewise immune. Id. A municipality does not
waive immunity by providing benefits to its employees, whether through as self-
funded plan or otherwise. See Tex. Gov’t Code §§ 2259.001, 2259.002 (stating
that a municipality does not waive immunity by establishing a self-funded plan);
see also Gay v. City of Wichita Falls, 457 S.W.3d 499, 505 (Tex. App.—El Paso
Aug. 13, 2014, no pet.) (holding that a city was immune from suit when it provided
benefits to its employees, citing Texas Gov’t Code Chapter 271 and Tooke v. City
of Mexia, 197 S.W.3d 325, 332 (Tex. 2006). Appellants did not waive immunity
by offering benefits to eligible employees of the City and their dependents.
Richardson Hosp. Auth. v. Duru, 387 S.W.3d 109, 113 (Tex. App.—Dallas 2012,
no pet.) (holding that a municipality did not waive immunity by offering insurance
JOINT APPELLANTS’ BRIEF - Page 7
to employees, because such contracts did not fall within the waiver of immunity in
Tex. Local Gov’t Code § 271.152); Foster v. Teacher Ret. Sys., 273 S.W.3d 883,
886 (Tex. App.—Austin 2008, no pet.) (holding that a state agency did not waive
immunity by providing benefits via a self-funded plan). Accordingly, Appellants
are immune from suit, and this Court should reverse the Trial Court’s ruling and
enter judgment dismissing Appellee’s claims.
D. Appellee Has Not Pled a Valid Waiver of Immunity.
In his amended petition, Appellee asserts that (1) Appellants were not
entitled to immunity because they were performing a proprietary function, and (2)
in the alternative, Appellants waived their immunity pursuant to Section 271.152,
because the documents establishing the Plan constitute a contract under which
services were provided to the City. Appellee has failed to plead a valid waiver of
immunity, and this Court should reverse the Trial Court and dismiss his claims.
1. The Proprietary/Governmental Function Distinction Does Not Apply.
The legislature, in enacting Texas Local Government Code Chapter 271,
refused to apply the distinction between proprietary and governmental functions to
claims for breach of contract, and it therefore has no application here. See
Republic Power Partners, L.P. v. City of Lubbock, 424 S.W.3d 184, 190-191 (Tex.
App.—Amarillo 2014, no pet.); Gay v. City of Wichita Falls, 457 S.W.3d 499, 505
(Tex. App.—El Paso 2014, no pet.); City of San Antonio ex rel. City Pub. Serv. Bd.
JOINT APPELLANTS’ BRIEF - Page 8
v. Wheelabrator Air Pollution Control, Inc., 381 S.W.597, 605 (Tex. App.—San
Antonio 2012, pet. denied).
Further, the legislature has expressly stated that the establishment of a self-
funded plan does not waive Appellants’ immunity. See Tex. Gov’t Code §§
2259.001, 2259.002 (stating that a municipality does not waive immunity by
establishing a self-funded plan); see also Humana Ins. Co. v. Mueller, 2015 WL
1938657, No. 04-14-752-CV (Tex. App.—San Antonio, April 29, 2015, no pet. h.)
(holding that establishing a self-funded plan did not waive immunity of a
governmental entity).
Appellee’s reliance, in his pleadings in the Trial Court, on City of
Georgetown v. Lower Colorado River Authority, 413 S.W.3d 803 (Tex. App.—
Austin 2013, pet. dism’d) is misplaced. First, City of Georgetown involved a
contract between a city and its electrical supplier. Id. This case, in contrast
involves a suit against a self-funded plan established by the City for its employees,
and the legislature has stated expressly that a municipality does not waive
immunity by establishing a self-funded plan. See Gov’t Code § 2259.002. Second,
the distinction between proprietary and governmental functions relied on in City of
Georgetown has been rejected by numerous courts since, and is no longer valid.
See, e.g., Republic Power, 424 S.W.3d at 184; Gay, 457 S.W.3d at 505.
JOINT APPELLANTS’ BRIEF - Page 9
2. Appellee did not plead a valid waiver of immunity under Chapter 271.
In order to plead a valid waiver of immunity under Chapter 271, Appellee
must show that the contract provides for the provision of goods and services to the
local governmental entity. Tex. Loc. Gov’t Code § 271.151. The contract at issue
in this case does not provide for services to a local governmental entity, and
Appellants did not allege or show that any services were provided to the City
pursuant to the Plan. Accordingly, Appellants did not waive immunity. See, e.g.,
Lubbock County Water Control & Imp. Dist. v. Church & Akin, L.L.C., 442
S.W.3d 297, 303 (Tex. 2014) (holding that the provision of services to a water
district’s constituents did not constitute the provision of services to the water
district, and therefore immunity was not waived under Chapter 271); East Houston
Estate Apartments, LLC v. City of Houston, 294 S.W.3d 723, 726 (Tex. App.—
Houston [1st Dist.] 2009, no pet.). Inasmuch as Appellee was not providing
services to the City under the contract sued on, the Plan is not a contract subject to
section 271.151. Id.
PRAYER
For the foregoing reasons, Appellants request that this Court reverse the
Trial Court’s order denying Appellants’ plea to the jurisdiction and render
judgment dismissing Appellee’s claims.
JOINT APPELLANTS’ BRIEF - Page 10
Respectfully submitted,
By: /s/ Lance V. Clack
Andrew G. Jubinsky
Texas Bar No. 11043000
andy.jubinsky@figdav.com
Lance V. Clack
Texas Bar No. 24040694
lance.clack@figdav.com
FIGARI & DAVENPORT, L.L.P.
901 Main Street, Suite 3400
Dallas, Texas 75202
Tel: (214) 939-2000
Fax: (214) 939-2090
ATTORNEYS FOR THE UNITED HEALTHCARE
CHOICE PLUS PLAN FOR CITY OF AUSTIN
EMPLOYEES
KAREN M. KENNARD, CITY ATTORNEY
MEGHAN L. RILEY, CHIEF LITIGATION
By: /s/ Megan Mosby
Andralee Cain Lloyd
State Bar No. 24071577
andralee.lloyd@austintexas.gov
Megan Mosby
State Bar No. 24073392
megan.mosby@austintexas.gov
City of Austin – Law Department
P. O. Box 1546
Austin, Texas 78767-1546
Tel: (512) 974-2918
Fax: (512) 974-1311
ATTORNEYS FOR CITY OF AUSTIN
JOINT APPELLANTS’ BRIEF - Page 11
CERTIFICATE OF COMPLIANCE
This document complies the word-count limitations of Rule 9.4(i)(3)
because it contains 1,922 words as calculated per the word processing program
used for its preparation, excluding any parts exempted by Rule 9.4(i)(1).
/s/ Lance V. Clack
Lance V. Clack
CERTIFICATE OF SERVICE
On the 24th day of June, 2015, a true and correct copy of the foregoing
document was served on counsel as follows:
Via E-Service
Amar Raval
araval@plummerlawyers.com
James C. Plummer
jplummer@plummerlawyers.com
PLUMMER & KUYKENDALL
4203 Montrose Blvd., Suite 270
Houston, Texas 77006
Attorney for Plaintiff
/s/ Lance V. Clack
Lance V. Clack
JOINT APPELLANTS’ BRIEF - Page 12
APPENDIX