Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca5-14-20506/USCOURTS-ca5-14-20506-0/pdf.json

Parties Involved:
Great-West Healthcare of Texas, Incorporated
Appellee
Kelsey-Seybold Medical Group PA
Appellant

Document Text:

IN THE UNITED STATES COURT OF APPEALS

FOR THE FIFTH CIRCUIT

No. 14-20506

KELSEY-SEYBOLD MEDICAL GROUP PA, doing business as KelseySeybold Clinic, 

 Plaintiff–Appellant,

v.

GREAT-WEST HEALTHCARE OF TEXAS, INCORPORATED, 

 Defendant–Appellee.

Appeals from the United States District Court

For the Southern District of Texas

USDC No. 4:07-CV-640

Before KING, SMITH, and ELROD, Circuit Judges.

PER CURIAM:*

Kelsey-Seybold Medical Group PA (Kelsey) sued Great-West Healthcare 

of Texas, Inc., (Great-West) in Texas state court, alleging that Great-West had 

not paid the contractually required rate for medical services that Kelsey had 

provided to members of Great-West-affiliated healthcare plans. Great-West 

removed the case to federal court on the ground that Kelsey’s claims were 

 

* 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.

United States Court of Appeals

Fifth Circuit

FILED

August 10, 2015

Lyle W. Cayce

Clerk

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No. 14-20506

2

completely preempted by the Employee Retirement Income Security Act 

(ERISA).1 Kelsey moved to remand on the basis that its claims were not 

completely preempted and, therefore, the district court lacked subject matter 

jurisdiction. The district court declared the claims preempted and entered a 

take-nothing judgment in favor of Great-West.

To determine whether a claim is completely preempted by ERISA, we 

apply the two-part test set forth in Aetna Health Inc. v. Davila: a claim is 

completely preempted if (1) the claimant “could have brought his claim under 

ERISA § 502(a)(1)(B),” and (2) “there is no other independent legal duty that 

is implicated by a defendant’s actions.” 542 U.S. 200, 210 (2004). In Lone Star 

OB/GYN Associates v. Aetna Health Inc., 579 F.3d 525 (5th Cir. 2009), we held

that “[a] claim that implicates the rate of payment as set out in the Provider 

Agreement, rather than the right to payment under the terms of the benefit 

plan, does not run afoul of Davila and is not preempted by ERISA.” Id. at 530.

This is because a dispute concerning only the contractual rate of payment is a 

breach-of-contract claim, not an ERISA claim. Thus, where a “partial payment 

. . . resulted from a denial of benefits under the plan, the claim may be 

preempted,” id. at 533, but “where claims do not involve coverage 

determinations, but have already been deemed ‘payable,’ and the only 

remaining issue is whether they were paid at the proper contractual rate, 

ERISA preemption does not apply,” id. at 532.

Great-West bears the burden of showing that removal was proper and 

establishing federal jurisdiction. Great-West has not satisfied its burden, as 

it has not identified any claims that “implicate coverage determinations under 

 

1 “Complete preemption converts a state law civil complaint alleging a cause of action 

that falls within ERISA’s enforcement provisions into ‘one stating a federal claim for 

purposes of the well-pleaded complaint rule.’” Lone Star OB/GYN Assocs. v. Aetna Health 

Inc., 579 F.3d 525, 529 (5th Cir. 2009) (quoting Aetna Health Inc. v. Davila, 542 U.S. 200, 209 

(2004)).

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No. 14-20506

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the terms of the relevant plan.” Id. at 533. Great-West contends that “about 

98% of Kelsey’s claims are claims for ERISA plan benefits,” but that fact is 

irrelevant; the question is not whether plaintiff’s claims relate to benefits

under ERISA plans, but rather whether adjudication of those claims requires

an interpretation of an ERISA plan. Great-West has not shown that any of 

Kelsey’s claims concern “the right to payment under the terms of the benefit 

plan,” as opposed to “the rate of payment as set out” in the parties’ contractual 

agreement. Lone Star, 579 F.3d at 533. Thus, Great-West has not satisfied its 

burden to establish federal jurisdiction.

We REVERSE the judgment of the district court and REMAND, with 

instructions for the district court to remand the case to state court. Given that 

this case is more than eight years old, we expect the district court to remand 

the case promptly.

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