United States Ex Rel. Morton v. a Plus Benefits, Inc.

F I L E D
United States Court of Appeals
Tenth Circuit
UNITED STATES COURT OF APPEALS
July 19, 2005
TENTH CIRCUIT
PATRICK FISHER
Clerk
UNITED STATES OF AMERICA ex
rel. WILL and COURTNEY
MORTON,
Plaintiffs-Appellants,
No. 04-4148
v. (D.C. No. 2:03-CV-711-DS)
(D. Utah)
A PLUS BENEFITS, INC. and
EVEREST ADMINISTRATORS,
Defendants-Appellees.
ORDER AND JUDGMENT *
Before KELLY , BRISCOE , and LUCERO , Circuit Judges.
Relators Will and Courtney Morton appeal the dismissal of a qui tam action
brought by them against A Plus Benefits, an ERISA Plan administrator, and
Everest Administrators, the contract administrator for the Plan, under the False
Claims Act (“FCA”), 31 U.S.C. §§ 3729-3733. FCA qui tam provisions “permit
private individuals to sue on behalf of the United States those persons or entities
*
This order and judgment is not binding precedent, except under the
doctrines of law of the case, res judicata, and collateral estoppel. The court
generally disfavors the citation of orders and judgments; nevertheless, an order
and judgment may be cited under the terms and conditions of 10th Cir. R. 36.3.
who allegedly have caused false or fraudulent claims to be presented to the
federal government.” United States ex rel. King v. Hillcrest Health Center, Inc.,
264 F.3d 1271, 1275 (10th Cir. 2001). In their complaint, the Mortons allege that
defendants’ improper denial of medical insurance coverage for their premature
infant, and defendants’ “direction” to file the medical claim with Medicaid,
constituted Medicaid fraud. The district court dismissed the Mortons’ complaint
under Fed. R. Civ. P. 12(b)(6), concluding that they had failed to assert a claim
under the FCA because they failed to allege a false or fraudulent claim. We
AFFIRM.
I
Specifically, the Mortons pleaded in their complaint that A Plus and
Everest unreasonably denied health benefits for medical treatment provided to
their son, Mitchell Morton (“Mitchell”), which resulted in the Utah State
Medicaid program’s payment of these expenses. Plaintiffs contend that Mitchell’s
medical expenses should have been paid under the terms of the ERISA employee
welfare benefit plan (“the Plan”) sponsored by A Plus Benefits, 1 and that by
denying Mitchell’s claims, defendants fraudulently shifted the cost of his care to
the taxpayers. The Mortons contend that the reasons given by defendants for
1
A contemporaneous ERISA lawsuit was filed by the Mortons in district
court.
2
denying Mitchell’s claims, which arise from Mitchell’s premature birth and
subsequent extensive medical treatment, were unreasonable to a degree that, when
combined with what they contend was a “direction” to file the claims with
Medicaid, the statements constitute a violation of the FCA.
Although the Plan paid for two months of medical treatment following
Mitchell’s birth, it denied further coverage on the basis that the subsequent care
was “custodial” and not covered by the Plan. In the letter notifying the health
care providers of the Plan’s determination on further payment, Everest, acting as
the Plan’s claims administrator provided the following information, which the
Mortons contend is a “direction” to file the claims for Mitchell’s medical care
with Medicaid:
It is this Plan’s preliminary determination, based on the information
available to the Plan, that Mitchell Morton’s care after May 31, 2001,
is custodial, and therefore not covered by this Plan . . . . If the
information is not already in your files, Mitchell Morton’s Medicaid
ID is [number] and his case manager is Cherie Morgan . . . . Due to
an inquiry to the Plan from the Utah State Medicaid office, Ms.
Morgan is already aware of this Plan’s preliminary determination in
this case.
(Appellants’ App. at 14). Payment by Medicaid would not have been necessary or
available but for the denial of coverage by the Plan.
II
We review de novo a district court’s dismissal under Rule 12(b)(6). Adams
v. Kinder-Morgan, Inc., 340 F.3d 1083, 1092 (10th Cir. 2003). Such “dismissal is
3
inappropriate unless plaintiff can prove no set of facts in support of his claims
that would entitle him to relief.” Dill v. City of Edmond, 155 F.3d 1193, 1201
(10th Cir. 1998). A court’s function on a Rule 12(b)(6) motion “is not to weigh
potential evidence that the parties might present at trial, but to assess whether the
plaintiff’s complaint alone is legally sufficient to state a claim for which relief
may be granted.” Proctor & Gamble Co. v. Haugen, 222 F.3d 1262, 1278-79
(10th Cir. 2000). When we review a dismissal under 12(b)(6) we must “accept all
the factual allegations in the complaint as true,” Leonhardt, 160 F.3d at 634, and
construe them in the light most favorable to the plaintiff. See Aguilera v.
Kirkpatrick, 241 F.3d 1286, 1292 (10th Cir. 2001).
Applicable sections of the False Claims Act state:
(a) Liability for certain acts. – Any person who –
(1) knowingly presents, or causes to be presented, to an officer
or employee of the United States Government . . . a false or
fraudulent claim for payment or approval; [or]
(2) knowingly makes, uses, or causes to be made or used, a
false record or statement to get a false or fraudulent claim paid or
approved by the Government; [or]
(3) conspires to defraud the Government by getting a false or
fraudulent claim allowed or paid . . .
is liable to the United States Government for a civil penalty of not
less than $5000 and not more than $10,000, plus 3 times the amount
of damages which the Government sustains because of the act of that
person . . . .”
31 U.S.C. § 3729(a)(1)-(3).
In their complaint, the Mortons allege violations under all three subsections
4
of § 3729(a). First, under § 3729(a)(1), relators allege that the defendants’ false
statement – “that Mitchell’s medical expenses were not covered under the terms
of the Plan” – resulted in the illegal shifting of Mitchell’s medical expenses from
the Plan to Medicaid. Second, relators, under § 3729(a)(2), allege that defendants
knowingly made the same false statement to Medicaid, the relators, and Mitchell’s
health care providers “to get a false or fraudulent claim paid or approved by
Medicaid.” Third, under § 3729(a)(3), relators allege that the defendants
conspired to defraud the United States “by getting false or fraudulent claims
allowed or paid and by establishing and executing an illegal payment scheme to
the damage of the United States.” In dismissing the complaint with prejudice, the
district court ruled that “there is no false or fraudulent claim involved,” and that
because Everest was a disclosed agent of A Plus Benefits, as a matter of law,
Everest was not responsible for the conduct of its principal.
On appeal, the Mortons contend that their allegations were sufficient to
survive a motion to dismiss because they can prove a set of facts that would
entitle them to relief under the FCA. We disagree. “At least two elements are
necessary to state a claim under these provisions [of the FCA]: (1) a claim for
payment from the government, (2) that is false or fraudulent.” Boisjoly v.
Thiokol, Inc., 706 F.Supp. 795, 808 (D. Utah 1988).
The Mortons fail to allege the falsity required to sustain an FCA claim
5
against either A Plus Benefits or Everest. “[A] false or fraudulent claim” is a
common requirement of all three subsections of § 3729(a). Thus, if the factual
allegations do not support a conclusion that a “false or fraudulent claim” was
made, the case may not proceed under the FCA. The FCA does not define “false”
or “fraudulent,” but its falsity and scienter requirements are inseparable. See
United States ex rel. Lamers v. City of Green Bay, 168 F.3d 1013, 1018 (7th Cir.
1999); United States ex rel. Roby v. The Boeing Co., 100 F.Supp. 2d 619 (S.D.
Ohio 2000). Falsity under the FCA “does not mean ‘scientifically untrue’; it
means ‘a lie.’” Wang v. FMC Corp., 975 F.2d 1412, 1421 (9th Cir. 1992). At a
minimum the FCA requires proof of an objective falsehood. See Lamers, 168
F.3d at 1018; Hagwood v. Sonoma County Water Agency, 81 F.3d 1465, 1477-78
(9th Cir. 1996). “Expressions of opinion, scientific judgments, or statements as to
conclusions about which reasonable minds may differ cannot be false.” Roby,
100 F.Supp. 2d at 625.
A great amount of argument below, and on appeal, centers on defendants’
claim that discretionary decisions under an ERISA plan can never constitute the
falsity necessary to sustain a claim under the FCA. Defendants argue that because
the determination that Mitchell’s care was not covered by the Plan is a
discretionary decision, it is not an “objectively verifiable fact,” and cannot form
the basis for a false or fraudulent claim. Defendants also argue that the
6
disagreement over the coverage of the Plan is not susceptible of being proved true
or false, and as such falls squarely into the general rule that fraud cannot be
predicated on a mere expression of opinion. See Tyger Constr. Co., Inc. v. United
States, 28 Fed. Cl. 35 (1993). Relators’ complaint, however, alleges that the
interpretation of the Plan was “transparently bogus,” and defendants’ invocation
of the custodial care exclusion lacked “any reasonable basis,” such that
defendants’ interpretation of the Plan to exclude the type of medical care given to
Mitchell as custodial is “false.”
We agree that liability under the FCA must be predicated on an objectively
verifiable fact. Nonetheless, we are not prepared to conclude that in all instances,
merely because the verification of a fact relies upon clinical medical judgments,
or involves a decision of coverage under an ERISA plan, the fact cannot form the
basis of an FCA claim. In this case, the nature of neither the scientific nor
contract determinations inherent in the formation and evaluation of the allegedly
“false” statement is susceptible to proof of truth or falsity.
Relators’ claim that Mitchell’s care was covered by the Plan because the
medical care was therapeutic – versus custodial – requires resolution of two sets
of inherently ambiguous issues. First, it requires a scientific determination of
whether the medical care was custodial or therapeutic, and second, it requires a
determination of whether, as a matter of contract interpretation, Mitchell’s care
7
fell within the Plan’s definition of “custodial” care. Although not all clinical
diagnoses and characterizations of medical care are intrinsically ambiguous, the
determination of whether the care given to a premature infant is therapeutic is
necessarily ambiguous. In this case, the Plan’s custodial care exclusion is also
ambiguous, requiring determinations of the “primary purpose or result” or if care
is given for “non-therapeutic purposes.” 2 As in Tyger, the relators’ “complaint
frames certain allegations as opinions that would follow if the court were to find
the underlying facts consistent with [relators’] proof . . . [a]lthough the ‘opinion’
is an ultimate finding of fact, the pleading is tantamount to [relators’] own
opinion.” Tyger, 28 Fed. Cl. at 56. Expression of a legal opinion, in this case
depending, as it does, on the resolution of two sets of inherently ambiguous
2
The custodial care exclusion in the Plan defines “custodial care” as:
Expenses related in any way to care, regardless of setting, for which
a professional license is not required, and is primarily maintenance
care required due to the Participant’s inability to perform the
common activities of daily living. Any care for which the primary
result or purpose is to maintain, rather than to improve, the
Participant’s condition will be considered custodial . . . [and]
Services, supplies, or accommodations for care which 1. Does not
provide treatment of an illness or injury, or 2. Could be provided by
persons with [sic] professional skills or qualifications, or 3. Are
provided primarily to assist the person in daily living, or 4. Are for
the convenience, contentment, or other non therapeutic purposes, or
5. Maintain physical condition when there is no prospect of effecting
remission, or restoration of the patient to a condition where care
would not be required.
(Appellants’ App. at 32-33, 36) (emphasis added)
8
determinations by defendants, cannot form the basis for an FCA claim. See
Lamers, 168 F.3d at 1018 (“[I]mprecise statements or differences in interpretation
growing out of a disputed legal question are similarly not false under the FCA.”);
Wang, 975 F.2d at 1421 (“The Act is concerned about ferreting out ‘wrongdoing,’
not scientific errors. What is false as a matter of science is not, by that very fact,
wrong as a matter of morals.”); Tyger, 28 Fed. Cl. at 56 (noting that FCA liability
will not attach for a statement relating to a contract term that is incapable of a
precise definition, and fraud cannot be predicated on the mere expression of an
opinion). We therefore conclude that the Mortons have failed to allege the
required “false or fraudulent” claim, and as such, dismissal under Fed. R. Civ. P.
12(b)(6) was appropriate. 3 Accordingly, we AFFIRM.
ENTERED FOR THE COURT
Carlos F. Lucero
Circuit Judge
3
Because we resolve this appeal on this basis we do not address the
additional issues of whether the Mortons sufficiently alleged either the conspiracy
to defraud in their third claim, or the “presented” or “caused to be presented”
elements of their FCA claims.
9