Federal Appeals Court Rules En Banc against UnitedHealthcare in a Landmark ERISA and Provider Right Case

On October 5, 2012, the Federal Court of Appeals for the Fifth Circuit hands down an en banc decision against UnitedHealthcare in a landmark ERISA case: ERISA does not preempt a service provider's state law claims against an ERISA plan's insurer for negligent misrepresentation, promissory estoppel, and violations of the Texas Insurance Code. Federal Law ERISA protects healthcare providers.

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almost all healthcare and managed care cases appealed to the Supreme Court in the past 30 years were decided based on ERISA preemption

Hanover Park, Illinois (PRWEB) October 06, 2012

On October 5, 2012, The Federal Court Of Appeals for the Fifth Circuit hands down an en banc decision against Unitedhealthcare in a landmark ERISA case: ERISA does not preempt a service provider's state law claims against an ERISA plan's insurer for negligent misrepresentation, promissory estoppel, and violations of the Texas Insurance Code. ERISAclaim.com offers webinars to discuss the profound impact of this landmark court decision for healthcare providers, in seeking for the new remedies and the expanded scope of liabilities for health plans and health insurers in communicating and denying healthcare claims, because this Fifth Circuit en banc decision is significant for all healthcare providers and attorneys in appealing and litigating healthcare claims, and it is also a dramatic landscape change for health plans and insurers as well as defense attorneys with ERISA shield protections for decades against most healthcare provider claims.

“To successfully appeal and litigate healthcare claim denials, healthcare providers and their attorneys must be well informed of ERISA preemption in order to prevail for both ERISA claims and state law claims,” said Dr. Jin Zhou, President of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

“ERISA preemption has been the No. 1 defense by healthcare insurance industry for more than 95% of healthcare claims in the past 37 years,” said Dr. Zhou, “almost all healthcare and managed care cases appealed to the Supreme Court in the past 30 years were decided based on ERISA preemption.”

The case information: Access Mediquip, L.L.C. v. UnitedHealth Group, Inc., et al, Court of Appeals Docket #: 10-20868, United States Court of Appeals for the 5th Circuit, decided on 10/05/2012.

The fifth circuit en banc decision can be found at the Court website:
http://www.ca5.uscourts.gov/opinions/pub/10/10-20868-CV2.wpd.pdf

The fifth circuit panel decision can be found at the Court website:
http://www.google.com/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&cad=rja&ved=0CB8QFjAA&url=ftp%3A%2F%2Fopinions.ca5.uscourts.gov%2FbyDate%2FNov2011%2FNov08%2F10-20868-CV0.wpd.pdf&ei=XJhvUK2HIaWtygHb0YCgAg&usg=AFQjCNFcjyndxrREdmOAV8Ca1Uw94NtUEQ

DOL Access Mediquip Amicus Brief, in support of plaintiff-appellant, can be found on the DOL website:
http://www.dol.gov/sol/media/briefs/access-mediquip(A)-07-11-2012.htm

According to the Fifth Circuit en banc decision, “The court took en banc this case, which raises questions about the scope of liability of an ERISA plan administrator and fiduciary for allegedly misrepresenting a plan beneficiary’s coverage in its advice to a provider of health devices.”

Without any detailed explanation, the Court made a very short en banc decision: “Having reconsidered this case en banc, we reinstate the panel opinion and overrule, to the extent inconsistent with its reasoning, the court’s opinions in Cypress Fairbanks, Hermann I and Hermann II. The judgment of the district court is REVERSED and the case REMANDED for further proceedings consistent herewith.”

According to the DOL Access Mediquip Amicus Brief, the best explanation of the case fact, which represents daily headaches for most healthcare providers in their routine healthcare practice, here is the case story:

“STATEMENT OF THE CASE

    Plaintiff Access Mediquip, LLC ("Access") supplies medical devices to healthcare providers. Am. Compl. at ¶ 14. Typically, providers ask Access to furnish a medical device before the procedure using the device is performed. Id. Rather than sell the device to the provider, Access contacts the patient's insurer to confirm that the insurer will reimburse Access for the device and pay for Access's services. Id. at ¶ 19. Access generally refuses to procure or finance a device if the insurer tells Access that the patient is not covered, that the device or procedure is not covered, that pre-certification of the device is required and has been denied, or that Access may not directly bill the insurer for the device. Id. at ¶ 58.

    In this case, Access sued defendant-insurer UnitedHealthcare Insurance Company ("United") with respect to alleged misrepresentations concerning coverage and payment for Access devices for over two thousand patients covered by numerous health care plans. Access Mediquip L.L.C. v. UnitedHealthcare Ins. Co., 662 F.3d 376, 377 (5th Cir. 2011) (panel decision). The district court limited the summary judgment motions to three "test" cases that would serve as exemplars. Id. at 378.

    In each of these test cases, the patients obtained United's health insurance through participation in an ERISA health benefits plan. Access Mediquip L.L.C. v. UnitedHealth Group Inc., Case No. H–09–2965, 2010 WL 3909544, at *1 (S.D. Tex. Oct. 4, 2010) (district court decision). The facts of these cases are similar: a hospital asked Access to procure or finance a medical device for an operation. Id. When Access contacted United, a representative assured Access that the patient was covered and authorized Access to bill United directly for the device. Id. After Access provided the device for the procedure, United concluded that the applicable ERISA plan did not cover the procedure requiring the device and thus refused to fully pay for the device. Id. at *1-*3.”

To find out more about PPACA Claims and Appeals Compliance Services from ERISAclaim.com:
http://www.erisaclaim.com/products.htm

Located in a Chicago suburb in Illinois, for over 12 years, ERISAclaim.com is the only ERISA & PPACA consulting, publishing and website resource for healthcare providers in the country. ERISAclaim.com offers free webinars, basic and advanced educational seminars and on-site claims specialist certification programs for doctors, hospitals and commercial companies, as well as numerous pending national ERISA class action litigation support. Dr. Jin Zhou is regarded as the industry “Godfather of ERISA claims” for healthcare providers.

For any questions, please contact Dr. Jin Zhou, president of ERISAclaim.com, at 630-808-7237.


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Attachments

AMQ v. UHC en banc decision AMQ v. UHC en banc decision

5th Cir. AMQ v. UHC Decision on ERISA Pre-emption


AMQ v. UHC AMQ v. UHC

5th Cir. Panel Opinion - AMQ v. UHC