[PUBLISH]

IN THE UNITED STATES COURT OF APPEALS

FOR THE ELEVENTH CIRCUIT

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No. 19-13088

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D.C. Docket No. 4:18-cv-00158-HLM

HASMUKH PATEL, M.D., 

 Plaintiff-Appellant,

 versus

HAMILTON MEDICAL CENTER, INC.,

 Defendant-Appellee.

________________________

Appeal from the United States District Court

for the Northern District of Georgia

________________________

(July 30, 2020)

Before WILLIAM PRYOR, Chief Judge, ROSENBAUM and LUCK, Circuit 

Judges.

WILLIAM PRYOR, Chief Judge:

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This appeal requires us to decide whether a plaintiff may invoke the subjectmatter jurisdiction of a district court by seeking a declaratory judgment that a 

defendant enjoys no immunity from damages under a federal statute. After 

Hamilton Medical Center, Inc., suspended his medical staff privileges, Hasmukh 

Patel filed a complaint against the Medical Center that sought damages, an 

injunction against the suspension, and a declaration that the Health Care Quality 

Improvement Act, 42 U.S.C. § 11111(a)(1), provided no immunity from damages

to the Medical Center. Patel contended that the district court had federal-question 

jurisdiction over the request for declaratory relief and could exercise supplemental 

jurisdiction over his remaining claims, all of which arose under state law. The 

district court granted summary judgment in favor of the Medical Center. Because 

Patel’s request for a declaratory judgment does not fall within federal-question 

jurisdiction, we vacate the judgment against him and remand with instructions to 

dismiss his complaint for lack of subject-matter jurisdiction. 

I. BACKGROUND

Patel is a gastroenterologist in Dalton, Georgia, who has held medical staff

privileges at the Medical Center since 1982. The Medical Center, which is also 

located in Dalton, conditioned Patel’s privileges on his compliance with its bylaws 

and Credentials Policy. The Credentials Policy required Patel to be available to 

provide care for or to otherwise arrange coverage for his patients at all times. 

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This litigation concerns a suspension that the Medical Center levied against 

Patel for allegedly failing to provide coverage over his Thanksgiving vacation in 

November 2014. After a physician reported the gap to administrators from the 

Medical Center, two standing committees recommended suspending Patel’s 

privileges for more than 30 days. Patel, who insisted that he arranged coverage 

during his vacation, demanded a hearing. The hearing panel upheld the 

recommendation of the standing committees. Patel then appealed to a review panel, 

which reduced his suspension to 29 days but otherwise upheld the recommendation 

of the hearing panel.

Patel filed a complaint against the Medical Center that sought damages and 

injunctive relief under state law and a declaratory judgment that the Medical 

Center was not immune from damages under the Health Care Quality Improvement 

Act. See 42 U.S.C. § 11111(a)(1) (providing hospitals with immunity from 

damages that arise out of certain peer-review proceedings). Patel alleged that the 

district court had federal-question jurisdiction over his request for declaratory 

relief, 28 U.S.C. § 1331, and that it could exercise supplemental jurisdiction over 

his claims under state law, id. § 1367(a).

The district court granted the Medical Center’s motion for summary 

judgment. It ruled that the Health Care Quality Improvement Act provided 

immunity from damages to the Medical Center, that each of Patel’s state-law 

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claims failed on the merits, and that Patel abandoned several of those claims. Patel 

appealed only the ruling on his request for declaratory relief. 

II. STANDARD OF REVIEW

“The district court’s subject matter jurisdiction is a question of law that we 

review de novo.” United States v. Iguaran, 821 F.3d 1335, 1336 (11th Cir. 2016). 

III. DISCUSSION

“Longstanding principles of federal law oblige us to inquire sua sponte

whenever a doubt arises as to the existence of federal jurisdiction.” Green v. 

Graham, 906 F.3d 955, 961 (11th Cir. 2018) (internal quotation marks omitted).

As inferior courts, federal circuit and district courts are “empowered to hear only 

those cases within the judicial power of the United States as defined by Article III 

of the Constitution[] and which have been entrusted to them by a jurisdictional 

grant authorized by Congress.” Univ. of S. Ala. v. Am. Tobacco Co., 168 F.3d 405, 

409 (11th Cir. 1999) (internal quotation marks omitted); see also Bryan A. Garner 

et al., The Law of Judicial Precedent § 65, at 551 (2016). In other words, an 

inferior court’s jurisdiction “must be both (1) authorized by statute and (2) within 

constitutional limits.” OFS Fitel, LLC v. Epstein, Becker & Green, P.C., 549 F.3d 

1344, 1355 (11th Cir. 2008). 

The record gives rise to questions both about whether statutory jurisdiction 

exists over this action, see 28 U.S.C. § 1331, and about whether this appeal 

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presents a justiciable controversy, see U.S. Const. art. III. For statutory 

jurisdiction, Patel contends only that federal-question jurisdiction exists over his 

suit, but a request for declaratory relief that a federal law does not entitle the 

opposing party to a defense ordinarily does not raise a federal question under 

section 1331. See First Fed. Sav. & Loan Ass’n of Lake Worth v. Brown, 707 F.2d 

1217, 1220 (11th Cir. 1983). And Patel may have deprived us of Article III 

jurisdiction when he appealed the denial of his request for a declaratory judgment 

without also challenging the ruling of the district court on his only claim that 

requested damages. Without an active claim that could produce damages, Patel 

might not have a legally cognizable interest in receiving a declaration that the 

Health Care Quality Improvement Act does not shield the Medical Center from 

damages. See Genesis Healthcare Corp. v. Symczyk, 569 U.S. 66, 72 (2013) 

(holding that a case is moot if “an intervening circumstance deprives the plaintiff 

of a personal stake in the outcome of the lawsuit” (internal quotation marks 

omitted)). 

Although mootness implicates our jurisdiction under Article III, we can

resolve this appeal on either jurisdictional ground. Even if mootness deprives us of 

jurisdiction to reach the merits, Article III leaves intact our statutory authority “to 

enter orders necessary and appropriate to the final disposition of a suit that is 

before us for review.” U.S. Bancorp Mortg. Co. v. Bonner Mall P’ship, 513 U.S. 

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18, 21–22 (1994); see also 28 U.S.C. § 2106 (“[A]ny . . . court of appellate 

jurisdiction may . . . vacate . . . any judgment, decree, or order of a court lawfully 

brought before it for review, and may remand the cause and direct the entry of such 

appropriate judgment . . . .”). And so “[i]f a judgment has become moot while 

awaiting review, [we] may not consider its merits, but may make such disposition 

of the whole case as justice may require.” Bancorp, 513 U.S. at 21 (alteration 

adopted) (quoting Walling v. James V. Reuter, Inc., 321 U.S. 671, 677 (1944)). In 

other words, we may “choose among threshold grounds for denying audience to a 

case on the merits” in this Court. Gardner v. Mutz, 962 F.3d 1329, 1336–38 (11th 

Cir. 2020) (internal quotation marks omitted) (vacating the judgment of the district 

court on standing grounds without resolving whether the suit became moot on 

appeal). 

In the light of this discretion, we start and end with the question of statutory 

jurisdiction. Because the Declaratory Judgment Act does not enlarge our 

jurisdiction, the plaintiff must still assert “an underlying ground for federal court 

jurisdiction.” Household Bank v. JFS Grp., 320 F.3d 1249, 1253 (11th Cir. 2003); 

see also 28 U.S.C. § 2201(a) (empowering district courts to enter declaratory 

judgments in “case[s] of actual controversy within [their] jurisdiction”). As 

discussed, Patel contends that his request for declaratory judgment establishes 

federal-question jurisdiction. See 28 U.S.C. § 1331. He does not raise any other 

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possible ground for statutory jurisdiction. Although Patel’s request for declaratory 

judgment turns on an issue of federal law, “we do not look to the face of the 

declaratory judgment complaint in order to determine the presence of a federal 

question.” Hudson Ins. Co. v. Am. Elec. Corp., 957 F.2d 826, 828 (11th Cir. 1992).

Federal-question jurisdiction exists “over a declaratory judgment action if . . . a 

plaintiff’s well-pleaded complaint alleges facts demonstrating the defendant could 

file a coercive action arising under federal law.” Household Bank, 320 F.3d at 

1259. 

Patel’s complaint does not establish that the Medical Center could file a 

coercive action under federal law. The Health Care Quality Improvement Act—the 

only federal law at issue—does not create a private right of action. See Bok v. Mut. 

Assurance, Inc., 119 F.3d 927, 929 (11th Cir. 1997). It creates an affirmative 

defense from damages. See Bryan v. James E. Holmes Reg’l Med. Ctr., 33 F.3d 

1318, 1332–33 (11th Cir. 1994). And a plaintiff cannot create federal-question 

jurisdiction by seeking a declaration that a federal defense does not protect the 

defendant. See Skelly Oil Co. v. Phillips Petroleum Co., 339 U.S. 667, 673–74 

(1950) (refusing to “sanction suits for declaratory relief as within the jurisdiction 

of the District Courts merely because . . . artful pleading anticipates a defense 

based on federal law”); Brown, 707 F.2d at 1220 (“A case does not present a 

federal question of the sort necessary to confer subject matter jurisdiction . . . 

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where it merely anticipates a federal question defense which the defendant might 

raise . . . .”). So Patel’s request for declaratory judgment does not establish federalquestion jurisdiction.

Patel contends that “he could be forced to defend a claim for liability for 

expenses of litigation under” the Health Care Quality Improvement Act, but he 

misinterprets the Act. The Act allows a court to award attorney’s fees “at the 

conclusion of the action” in some circumstances. 42 U.S.C. § 11113. Because 

Congress tied this provision to the underlying suit, the Medical Center could not

“file a coercive action” for attorney’s fees. Household Bank, 320 F.3d at 1259.

Patel also alleges that his suit “requires interpretation of a substantial federal 

issue and a substantial question of federal law,” but we would lack jurisdiction 

even if this allegation were true. To be sure, “federal jurisdiction over a state law 

claim will lie if a federal issue is: (1) necessarily raised, (2) actually disputed, (3) 

substantial, and (4) capable of resolution in federal court without disrupting the 

federal-state balance approved by Congress.” Gunn v. Minton, 568 U.S. 251, 258 

(2013). But to reiterate, our jurisdiction turns on whether the Medical Center 

“could file a coercive action arising under federal law,” Household Bank, 320 F.3d 

at 1259, and Patel’s complaint does not establish that the Medical Center could 

bring any claim against him, much less one that satisfies these four conditions. Cf. 

Iberiabank v. Beneva 41-I, LLC, 701 F.3d 916, 919 n.4 (11th Cir. 2012) (holding 

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that the district court had jurisdiction over a declaratory-judgment action because 

the defendant “likely could bring its own state contract claim, which would 

necessarily raise a federal question”). Nor do we see how a state claim could ever 

“necessarily raise” a federal issue under the Health Care Quality Improvement Act, 

which creates only an affirmative defense. Gunn, 568 U.S. at 258–59 (examining 

whether the elements of a claim under state law would implicate a federal 

question); Adventure Outdoors, Inc. v. Bloomberg, 552 F.3d 1290, 1297–98 (11th 

Cir. 2008) (holding that a claim under state law did not did not necessarily raise a 

federal issue when its elements did not implicate federal law). After all, affirmative 

defenses do not necessarily arise in suits. A defendant can forfeit an affirmative 

defense by failing to raise it, and “[a]n affirmative defense, once forfeited, is 

excluded from the case.” Wood v. Milyard, 566 U.S. 463, 470 (2012) (alteration 

adopted) (internal quotation marks omitted). 

The district court lacked jurisdiction over this suit. Patel has not met his 

burden to establish federal-question jurisdiction, and we see no other possible 

avenue for statutory jurisdiction. In the light of this defect, we need not address 

mootness and cannot consider the merits of this appeal.

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IV. CONCLUSION

We VACATE the judgment in favor of the Medical Center and REMAND

with instructions to DISMISS Patel’s complaint for lack of subject-matter 

jurisdiction.

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