W. A. Griffin, MD v. Health Systems Management, Inc.

Case: 15-12138 Date Filed: 12/29/2015 Page: 1 of 11
[DO NOT PUBLISH]
IN THE UNITED STATES COURT OF APPEALS
FOR THE ELEVENTH CIRCUIT
________________________
No. 15-12138
Non-Argument Calendar
________________________
D.C. Docket No. 1:15-cv-00171-AT
W. A. GRIFFIN, MD,
Plaintiff - Appellant,
versus
HEALTH SYSTEMS MANAGEMENT, INC.,
Defendant - Appellee.
________________________
Appeal from the United States District Court
for the Northern District of Georgia
________________________
(December 29, 2015)
Before MARTIN, JILL PRYOR and ANDERSON, Circuit Judges.
PER CURIAM:
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Proceeding pro se, Dr. W.A. Griffin appeals the dismissal of her complaint
under the Employee Retirement Income Security Act of 1974 (“ERISA”), 29
U.S.C. § 1132(a). After careful consideration, we affirm. 1
I.
Dr. Griffin, who operates a dermatology practice in Atlanta, Georgia, treated
a patient insured under a Health Systems Management, Inc. health plan (the
“Plan”).2 Dr. Griffin is an out-of-network provider for the Plan. The insured
executed an assignment that “assign[ed] and convey[ed]” to Dr. Griffin “all
medical benefits and/or insurance reimbursement, if any, otherwise payable to me
for services rendered from [Dr. Griffin] . . . , regardless of [Dr. Griffin’s] managed
1
Dr. Griffin’s motions for (1) a three-judge panel and a published opinion and (2)
expedited consideration, a three-judge panel, and a published opinion are also pending before us.
We deny her motion. Her requests for a three-judge panel are moot because our rules provide
that she is entitled to a three-judge panel. See 11th Cir. R. 34-2, 34-3(e). As regards her requests
for a published opinion, our rules provide that “[a]n opinion shall be unpublished unless a
majority of the panel decides to publish it.” 11th Cir. R. 36-2. In this case, the panel decided not
to publish. Our rules do permit a party to file a motion requesting that a previously unpublished
order be published but provide that the motion shall be granted only if the panel unanimously
agrees to publish. 11th Cir. R. 36-3. Construing Dr. Griffin’s motions as requesting publication
under Rule 36-3, the request is premature, and we deny it. Finally, we deny her request for
expedited consideration as moot.
2
At the motion to dismiss stage, we accept the well-pleaded allegations in the complaint
as true and view them in the light most favorable to Dr. Griffin. See Chaparro v. Carnival
Corp., 693 F.3d 1333, 1335 (11th Cir. 2012). We also consider the Medical Benefit Booklet
regarding the Plan, which Health Systems Management submitted to the district court with its
motion to dismiss. Although Dr. Griffin did not attach this document to her complaint, we may
consider it because it is central to the complaint and its contents are not in dispute. See Harris v.
Ivax Corp., 182 F.3d 799, 802 n.2 (11th Cir. 1999).
2
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care network participation status.” Legal Assignment of Benefits (Doc. 1-1). 3 The
assignment further stated that it was “valid for all administrative and judicial
review under . . . ERISA.” Id.
The Plan is a group health benefit plan governed by ERISA. Health Systems
Management sponsors the Plan and serves as the plan administrator. Blue Cross
Blue Shield of Georgia (“BCBSGA”) serves as the Plan’s claims administrator to
review and decide claims and appeals under the Plan. An anti-assignment
provision in the Plan documents generally bars participants from assigning benefits
under the Plan. See Medical Benefit Booklet at 63 (Doc. 5-2) (“You cannot assign
your right to receive payment to anyone else, except as required by a ‘Qualified
Medical Child Support Order’ as defined by ERISA or any applicable state law.”).
Dr. Griffin submitted two claims to BCBSGA for services she provided to
the insured. She alleges BCBSGA underpaid these claims. She filed with
BGBSGA separate level one administrative appeals for both claims. With each
administrative appeal, Dr. Griffin requested at least ten categories of documents
from BCBSGA. She also demanded that BCBSGA notify her whether the Plan
contained an anti-assignment clause, warning that if it failed to do so, she would
argue in litigation that the anti-assignment clause was unenforceable. BCBSGA
denied the appeals. She then filed with BCBSGA a level two administrative
3
Citations to “Doc.” refer to docket entries in the district court record in this case.
3
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appeal for each claim. BCBSGA denied one of the appeals and failed to respond
to the other. BCBSGA never provided Dr. Griffin with any of the documents she
requested with her level one appeal nor disclosed that the Plan had an anti-
assignment provision.
Dr. Griffin sued Health Systems Management in federal court, bringing
ERISA claims for unpaid benefits, breach of fiduciary duty, failure to provide Plan
documents, and breach of contract. She sought approximately $7,700 in unpaid
benefits, at least $186,000 in penalties, and declaratory relief. Health Systems
Management moved to dismiss the complaint. While the motion to dismiss was
pending, Dr. Griffin sought leave to amend her complaint to add an additional
claim based upon co-fiduciary liability under ERISA. The district court granted
the motion to dismiss and denied the motion to amend, concluding that Dr. Griffin
lacked statutory standing under ERISA based on the Plan’s anti-assignment
provision. Accordingly, the district court dismissed the case without prejudice.
This appeal followed.
II.
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
4
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rather whether the plaintiff “has a cause of action under the statute.” Lexmark
Int’l, Inc. v. Static Control Components, Inc., 134 S. Ct. 1377, 1387-88 & n.4
(2014) (internal quotation marks omitted). Put differently, we understand the
district court’s decision that Dr. Griffin lacked statutory standing to be a
determination that she failed to state a claim under Federal Rule of Civil Procedure
12(b)(6). See City of Miami v. Bank of Am. Corp., 800 F.3d 1262, 1273-74 (11th
Cir. 2015).
“We review de novo the district court’s grant of a Rule 12(b)(6) motion to
dismiss for failure to state a claim, accepting the complaint’s allegations as true
and construing them in the light most favorable to the plaintiff.” Chaparro v.
Carnival Corp., 693 F.3d 1333, 1335 (11th Cir. 2012) (internal quotation marks
omitted). 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.” Bell Atlantic Corp. v. Twombly, 550 U.S. 544, 570 (2007). “[N]aked
assertions devoid of further factual enhancement” or “[t]hreadbare recitals of the
elements of a cause of action, supported by mere conclusory statements, do not
suffice.” Ashcroft v. Iqbal, 566 U.S. 662, 678 (2009) (internal quotation marks
omitted). Upon review of dismissals for failure to state a claim, “[p]ro se
pleadings are held to a less stringent standard than pleadings drafted by attorneys
5
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and are liberally construed.” Bingham v. Thomas, 654 F.3d 1171, 1175 (11th Cir.
2011) (internal quotation marks omitted).
III.
Section 502(a) of ERISA provides that only plan participants and plan
beneficiaries may bring a private civil action to recover benefits due under the
terms of a plan, to enforce rights under a plan, or to recover penalties for a plan
administrator’s failure to provide documents. 29 U.S.C. § 1132(a)(1), (c). This
provision also limits the right to sue for breach of fiduciary duty to plan
participants, plan beneficiaries, plan fiduciaries, and the Secretary of Labor. Id.
§ 1132(a)(2). Additionally, only plan participants, plan beneficiaries, and plan
fiduciaries may bring a civil action to obtain equitable relief to redress a practice
that violates ERISA or the terms of a plan. Id. § 1132(a)(3). As we have
explained, “[h]ealthcare providers . . . are generally not ‘participants’ or
‘beneficiaries’ under ERISA and thus lack independent standing to sue under
ERISA.” Physicians Multispecialty Grp. v. Health Care Plan of Horton Homes,
Inc., 371 F.3d 1291, 1294 (11th Cir. 2004).
There is, however, an exception to this general rule that healthcare providers
have no right of action under section 502(a). We have recognized that
“[h]ealthcare providers may acquire derivative standing . . . by obtaining a written
assignment from a ‘beneficiary’ or ‘participant’ of his right to payment of benefits
6
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under an ERISA-governed plan.” Id; see also Cagle v. Bruner, 112 F.3d 1510,
1515 (11th Cir. 1997) (explaining that “neither the text of § 1132(a)(1)(B) nor any
other ERISA provision forbids the assignment of health care benefits provided by
an ERISA plan”). Although ERISA does not prohibit a plan participant or
beneficiary from assigning benefits to her provider, we have held that an anti-
assignment provision in a plan, which limits or prohibits a plan participant or
beneficiary from assigning her right to payment of benefits, is valid and
enforceable. Physicians Multispecialty Grp., 371 F.3d at 1296. Accordingly, an
anti-assignment provision can bar a plan participant or beneficiary from assigning
benefits to a healthcare provider, meaning the healthcare provider cannot acquire a
cause of action under section 502(a). Id.
A.
In this case, the insured’s assignment purported to transfer to Dr. Griffin the
right to payment of benefits from the Plan. We have recognized that when a patient
assigns to a provider the right to payment for medical benefits, he also conveys the
right to file an action under section 502(a) of ERISA for unpaid benefits. See
Conn. State Dental Ass’n v. Anthem Health Plans, Inc., 591 F.3d 1337, 1352-53
(11th Cir. 2009). Thus, if enforceable, the assignment transferred to Dr. Griffin the
7
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right to bring a cause of action under section 502(a) for unpaid benefits.4 But the
Plan’s anti-assignment provision bars the insured’s assignment to Dr. Griffin.
The anti-assignment provision states “You cannot assign your right to
receive payment to anyone else, except as required by a ‘Qualified Medical Child
Support Order’ as defined by ERISA or any applicable state law.” Medical Benefit
Booklet at 63 (Doc. 5-2). Construing this provision to mean that the Plan must
permit assignments that are required by state law, Dr. Griffin argues that the anti-
assignment provision is inapplicable because Georgia law required the insureds to
assign their benefits to her. 5 She relies on a Georgia statute stating that that
“whenever an accident and sickness insurance policy, subscriber contract, or self-
insured health benefit plan . . . provides that any of its benefits are payable to a
participating or preferred [licensed] provider of health care services,” the plan must
also “pay such benefits either directly to any similarly licensed nonparticipating or
nonpreferred provider who has rendered such services, has a written assignment of
4
Although the assignment transferred to Dr. Griffin the insured’s right to sue under
section 502(a) of ERISA for unpaid benefits, the assignment contained no provision transferring
the insured’s right to assert claims for breach of fiduciary duty or civil penalties. Because the
insured never assigned to Dr. Griffin the right to bring such claims, she lacks derivative standing
to bring these claims under section 502 of ERISA.
5
The anti-assignment provision could be interpreted in two ways. As Dr. Griffin asserts,
the provision may be read as allowing assignments required by (1) a Qualified Medical Child
Support Order, as that term is defined by ERISA, or (2) applicable state law. Alternatively, the
provision may be read as allowing assignments only when required by a Qualified Medical Child
Support Order, as that term is defined by either (1) ERISA or (2) applicable state law. Under the
second interpretation, the insured’s assignments to Dr. Griffin would be void because it was not
made pursuant to a Qualified Medical Child Support Order. We assume for purposes of this
appeal that the Plan permits assignments when required by state law.
8
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benefits, and has caused written notice of such assignment to be given . . . or
jointly to such nonparticipating or nonpreferred provider and to the insured.”
O.C.G.A. § 33-24-54(a). These benefit payments must be sent “directly to the
provider who has the written assignment.” Id. The statute guarantees that if
benefits are payable to preferred or participating providers under a plan, the plan
must also pay benefits to non-participating or non-preferred healthcare providers to
whom patients have assigned their rights. But nothing in this statute requires an
insured to assign her benefits to a medical provider. 6 Accordingly, we conclude
that even though the insured assigned benefits to Dr. Griffin, the assignment is
void.
B.
Dr. Griffin argues that Health Systems Management cannot rely on the anti-
assignment provision because BCBSGA failed to notify her of the provision after
she asked whether the Plan contained such a term. Liberally construed, Dr.
Griffin’s argument is that because BCBSGA failed to disclose the anti-assignment
term, Health Systems Management either is equitably estopped from relying on the
anti-assignment term or has waived it. We disagree.
6
Dr. Griffin makes an alternative argument that even if the Plan prohibits the
assignments, the anti-assignment provision is void under section 33-25-54. We reject this
argument for a related reason: nothing in this statute explicitly prohibits a health benefits plan
from barring assignments. We fail to see how section 33-24-54 renders an anti-assignment
provision unenforceable and decline to hold that the statute implicitly bars anti-assignment
provisions.
9
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Under ERISA equitable estoppel applies only when “the plaintiff can show
that (1) the relevant provisions of the plan at issue are ambiguous, and (2) the plan
provider or administrator has made representations to the plaintiff that constitute an
informal interpretation of the ambiguity.” Jones v. Am. Gen. Life & Acc. Ins. Co.,
370 F.3d 1065, 1069 (11th Cir. 2004). Even if the anti-assignment provision is
ambiguous, there is no evidence that Health Systems Management or BCBSGA
made any representation to Dr. Griffin informally interpreting the provision.
Accordingly, equitable estoppel cannot apply here.
We have “left open the question of whether waiver principles might apply
under the federal common law in the ERISA context.” Witt v. Metro. Life Ins. Co.,
772 F.3d 1269, 1279 (11th Cir. 2014). But even if we assume that waiver could
apply in the ERISA context, Dr. Griffin has failed to plead sufficient facts to show
that Health Systems Management waived the anti-assignment provision.
“[W]aiver is the voluntary, intentional relinquishment of a known right.”
Id. (internal quotation marks omitted). We have explained that waiver may be
express or implied, but to find implied waiver, “the acts, conduct, or circumstances
relied upon to show waiver must make out a clear case.” Dooley v. Weil (In re
Garfinkle), 672 F.2d 1340, 1347 (11th Cir. 1982).
Dr. Griffin has neither alleged nor explained how Health Systems
Management intentionally relinquished its rights under the anti-assignment
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provision. In fact, she alleged no interaction or communication with Health
Systems Management before she filed this lawsuit. Although she alleged that
BCBSGA failed to inform her of the anti-assignment provision during the
administrative process, even liberally construing her pleadings and accepting her
allegations as true, we find these allegations insufficient to establish a “clear case”
that Health Systems Management intentionally and voluntarily relinquished its
rights under the anti-assignment provision. Id. 7
IV.
We conclude that the Dr. Griffin failed to state a claim because she failed to
allege facts sufficient to support a cause of action under § 502(a) of ERISA.
Accordingly, the district court committed no error in dismissing her complaint
against Health Systems Management. 8
AFFIRMED.
7
We express no opinion about whether Dr. Griffin’s allegations would be sufficient to
plead that BCBSGA waived the anti-assignment provision, as that question is not before us.
8
Dr. Griffin also argues that the district court erred in denying her motion to amend her
complaint to add an additional claim under ERISA. We review the district court’s denial of a
motion to amend a complaint for abuse of discretion, but we review de novo whether the
proposed amendment to the complaint would be futile. See Harris v. Ivax Corp., 182 F.3d 799,
802-03 (11th Cir. 1999). Because of the anti-assignment provision, Dr. Griffin has no right of
action under ERISA, thus, the proposed amendment would be futile, and the district court
properly denied the motion to amend.
11