Title: Hendrix v. United Healthcare Insurance Company of the River Valley
Citation: N/A
Docket Number: 1190107
State: Alabama
Issuer: Alabama Supreme Court
Date: September 18, 2020

Rel: September 18, 2020
Notice: This opinion is subject to formal revision before publication in the advance
sheets of Southern Reporter.  Readers are requested to notify the Reporter of Decisions,
Alabama Appellate Courts, 300 Dexter Avenue, Montgomery, Alabama 36104-3741 ((334)
229-0649), of any typographical or other errors, in order that corrections may be made
before the opinion is printed in Southern Reporter.
SUPREME COURT OF ALABAMA
 SPECIAL TERM, 2020
_________________________
1190107
_________________________
Kathleen Hendrix, as administratrix of the Estate of Kenneth
Morris Hendrix, deceased
v.
United Healthcare Insurance Company of the River Valley
Appeal from Etowah Circuit Court
(CV-17-900732)
SELLERS, Justice.
Kathleen Hendrix ("Hendrix"), as administratrix of the
estate of Kenneth Morris Hendrix, deceased, appeals from a
judgment of the Etowah Circuit Court, dismissing Hendrix's
medical-malpractice wrongful-death claim against United
1190107
Healthcare Insurance Company of the River Valley ("United"). 
Kenneth, who was covered by a health-insurance policy issued
by United, died after United refused to pay for a course of
medical 
treatment 
recommended 
by 
Kenneth's 
treating 
physician. 
The trial court determined that Hendrix's claim is preempted
by the Employee Retirement Income Security Act of 1974, 29
U.S.C. § 1001 et seq. ("ERISA"), because the claim "relate[s]
to" 
the 
ERISA-governed employee-benefit plan 
pursuant 
to 
which
United had issued Kenneth's health-insurance policy.  See 29
U.S.C. § 1144(a) ("Except as provided in subsection (b) of
this section, the provisions of this subchapter and 
subchapter
III shall supersede any and all State laws insofar as they may
now or hereafter relate to any employee benefit plan ...."). 
We affirm the trial court's judgment.
Introduction
ERISA governs "voluntarily established health 
and 
pension
plans in private industry."  Kennedy v. Lilly Extended
Disability Plan, 856 F.3d 1136, 1138 (7th Cir. 2017).  It
"comprehensively regulates, among other things, employee
welfare benefit plans that, 'through the purchase of 
insurance
or otherwise,' provide medical, surgical, or hospital care, or
2
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benefits in the event of sickness, accident, disability, or
death. § 3(1), 29 U.S.C. § 1002(1)."  Pilot Life Ins. Co. v.
Dedeaux, 481 U.S. 41, 44 (1987).  
ERISA's express preemption provision, § 514(a), 29 U.S.C.
§ 1144(a), provides that ERISA "shall supersede any and all
State laws insofar as they may now or hereafter relate to any
employee benefit plan."  State law that may be preempted
because it relates to an ERISA employee-benefit plan "includes
all laws, decisions, rules, regulations, or other State action
having the effect of law."  29 U.S.C. § 1144(c)(1).  This
includes civil causes of action brought pursuant to state law. 
Aldridge v. DaimlerChrysler Corp., 809 So. 2d 785, 792 (Ala.
2001) ("ERISA's express preemption provision ... 'defeats
claims that seek relief under state-law causes of action that
"relate to" an ERISA plan.'" (quoting Butero v. Royal
Maccabees Life Ins. Co., 174 F.3d 1207, 1215 (11th Cir.
1999))); Seafarers' Welfare Plan v. Dixon, 512 So. 2d 23 (Ala.
1987) (holding that causes of action alleging breach of
contract and bad-faith failure to pay insurance benefits were
preempted by ERISA).  Thus, if Hendrix's cause of action
3
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against United "relate[s] to" an ERISA-governed plan, it is
preempted under § 514(a).1
In October 2015, Kenneth was injured in an automobile
accident.  He was admitted to Gadsden Regional Medical Center
for treatment.  Approximately one week later, a physician
treating Kenneth at the hospital ordered that he be admitted
to an inpatient-rehabilitation facility.  The complaint
indicates that Kenneth accepted his treating physician's
recommendation and that Kenneth "desired that [he] be 
admitted
to such an inpatient facility."  The complaint also indicates,
and Hendrix concedes, that the United health-insurance policy
covering Kenneth was issued as part of an ERISA-governed
employee-benefit plan administered by United ("the health-
benefit plan").  
According to the complaint, after Kenneth's treating
physician 
ordered 
inpatient 
rehabilitation, 
representatives 
of
the hospital and a rehabilitation facility "all contacted
[United] numerous times in an attempt to get [Kenneth]
admitted to an inpatient facility."  Hendrix asserts that
1Preemption under § 514(a) is referred to herein as
"defensive" preemption.  There is a distinction between the
concept of defensive preemption and "complete" preemption,
which is discussed later in this opinion.
4
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United then "imposed itself as [Kenneth's] health care
provider, took control of [Kenneth's] medical care, and made
a medical treatment decision that [Kenneth] should not 
receive
further treatment, rehabilitation, and care at an inpatient
facility."  Hendrix asserted in the complaint that, instead,
United "made the medical treatment decision that [Kenneth]
should be discharged to his home ... and receive a lower
quality of care (i.e., home health care) than had been ordered
by [his] physicians, therapists, and nurses."  Because United
rejected Kenneth's request for inpatient rehabilitation,
Kenneth was sent home.  Kenneth died on October 25, 2015, due
to a pulmonary thromboembolism, which, the complaint asserts,
would not have occurred had United approved inpatient
rehabilitation.
Alleging wrongful death under § 6-5-410, Ala. Code 1975,
Hendrix sued the estate of the other driver involved in the
automobile accident, that driver's employer, the owner of the
other vehicle involved in the accident, and United.2  In
support of her claim against United, Hendrix alleged medical
2Hendrix also sued Kenneth's own automobile insurer
seeking uninsured/underinsured-motorist benefits.
5
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malpractice under § 6-5-480 et seq., Ala. Code 1975, and § 6-
5-540 et seq., Ala. Code 1975.  Hendrix alleged that United
"voluntarily assumed one or more of the following
duties, jointly or in the alternative; (1) a duty to
act with reasonable care in determining the quality
of health care that [Kenneth] would receive; (2) a
duty to not provide to [Kenneth] a quality of health
care so low that it knew that [Kenneth] was likely
to be injured or killed; and/or (3) a duty to
exercise such reasonable care, skill, and diligence
as other similarly situated health care providers in
the same general line of practice ordinarily have
and exercise in a like case."
Hendrix alleged further that United
"negligently and wantonly breached the standard of
care 
that 
applied 
to 
[United's] 
voluntarily
undertaken duties in one or more of the following
respects: (a) by providing healthcare for [Kenneth]
that fell beneath the standard of care; (b) by
making the medical treatment decision and mandating
that [Kenneth] not receive further treatment,
rehabilitation, and care at an inpatient facility
following his discharge from [the hospital]; (c) by
violating a physician's orders which required that
[Kenneth] 
receive 
further 
treatment, 
rehabilitation,
and care at an inpatient facility following his
discharge from [the hospital]; (d) by interfering
with [Kenneth's] medical care and preventing him
from receiving further treatment, rehabilitation,
and care at an inpatient facility following his
discharge from [the hospital]."
Although somewhat vague, the complaint demonstrates that,
based on the recommendation of his treating physician at
Gadsden Regional Medical Center, Kenneth wanted to 
be 
admitted
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to an inpatient-rehabilitation facility, that his medical
providers requested United pay for that course of treatment
pursuant to an insurance policy that is part of an ERISA-
governed plan, that United denied that request, and that
Kenneth was unable to participate in inpatient rehabilitation
because United refused to pay for it.3
United removed Hendrix's action to the United States
District Court for the Northern District of Alabama.  In its
notice of removal, United asserted that federal-question
jurisdiction existed under 28 U.S.C. § 1331 because, United
contended, Hendrix's claim against United should be 
treated as
3We note that Kenneth's health-insurance policy, which is
referenced in Hendrix's complaint and was submitted to the
trial court along with United's motion to dismiss, provides
that United will pay for "a service, treatment, supply,
device, or item, Hospital, medical or otherwise, which is
medically necessary" as 
determined by United.  A determination
whether a recommended course of treatment is medically
necessary includes an analysis of whether the treatment "is
consistent with generally accepted principles of medical
practice" and is "cost-effective."  Hendrix's complaint
alleges that United made "the medical treatment decision" that
Kenneth should not be treated in an inpatient-rehabilitation
facility.  The complaint, however, does not allege that United
determined that inpatient rehabilitation was not medically
necessary and therefore not covered by the insurance policy. 
What is clear from the complaint, however, is that United
denied the request made by Kenneth's treating physician for
benefits under the United insurance policy and that Kenneth
did not go to inpatient rehabilitation because United refused
to pay for it.
7
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one seeking relief under the civil-enforcement provisions of
ERISA and was therefore completely preempted by ERISA. 
See ERISA § 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B)
(authorizing an ERISA plan participant or beneficiary to 
bring
a civil action "to recover benefits due to him under the terms
of his plan, to enforce his rights under the terms of the
plan, or to clarify his rights to future benefits under the
terms of the plan"); Garrison v. Northeast Georgia Med. Ctr.,
Inc., 66 F. Supp. 2d 1336, 1340 (N.D. Ga. 1999) ("[C]laims
seeking relief available from section 502(a), ERISA's civil
enforcement provision, 29 U.S.C. § 1132, are completely
preempted, and removal jurisdiction exists.").
In Aetna Health Inc. v. Davila, 542 U.S. 200 (2004), the
United States Supreme Court reiterated that the civil-
enforcement provisions set out in § 502(a) of ERISA have
complete preemptive effect and that state-law causes of 
action
that fit within the scope of those enforcement provisions are
to be treated as federal claims that can removed to federal
court.  According to the Court in Davila:
"[I]f an individual brings suit complaining of a
denial of coverage for medical care, where the
individual is entitled to such coverage only because
of the terms of an ERISA-regulated employee benefit
8
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plan, and where no legal duty (state or federal)
independent of ERISA or the plan terms is violated,
then the suit falls 'within the scope of' ERISA §
502(a)(1)(B). Metropolitan Life [Ins. Co. v. Taylor,
481 U.S. 58, 66 (1987)]. In other words, if an
individual, at some point in time, could have
brought his claim under ERISA § 502(a)(1)(B), and
where there is no other independent legal duty that
is implicated by a defendant's actions, then the
individual's 
cause 
of 
action 
is 
completely
pre-empted by ERISA § 502(a)(1)(B)."
542 U.S. at 210.  The federal district court in the present
case noted that Alabama's wrongful-death statute creates a
"new right" that arises after the decedent's death and allows
for the recovery of only punitive damages.  According to the
district court, "[b]ecause the wrongful-death claim vests in
the decedent's personal representative as a new right and does
not compensate for an injury to the ERISA beneficiary, but
instead provides punitive damages for next of kin," Hendrix
could not have brought her wrongful-death claim under ERISA §
502(a), her claim should not be treated as one seeking ERISA
benefits, complete preemption does not exist, and the cause
had to be remanded to state court.
After remand, United moved the trial court to dismiss
Hendrix's claim based on defensive preemption under ERISA's
express preemption provision, § 514(a).  As noted, § 514(a)
9
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provides that ERISA "shall supersede any and all State laws
insofar as they may now or hereafter relate to any employee
benefit plan."  29 U.S.C. § 1144(a) (emphasis added). 
According to United, Hendrix's medical-malpractice wrongful-
death claim "relate[s] to" the ERISA-governed health-benefit
plan and is therefore defensively preempted.  The trial court
agreed, granted United's motion to dismiss, and certified its
judgment as final under Rule 54(b), Ala. R. Civ. P.  Hendrix
appealed.4
Standard of Review 
The parties agree that the appropriate standard of review
in this case is the standard applicable to the granting of a
motion to dismiss under Rule 12(b)(6), Ala. R. Civ. P.  We
review such dismissals de novo.  Little v. Robinson, 72 So. 3d
1168, 1171 (Ala. 2011).  In reviewing the dismissal of a cause
of action based on an affirmative defense, we must decide
whether the existence of that defense is clear from the face
of the plaintiff's complaint.  Limon v. Sandlin, 200 So. 3d
21, 24 (Ala. 2015).  We must accept as true all the factual
4United's motion to dismiss was based solely on defensive
preemption under ERISA § 514(a).
10
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allegations set out in the complaint.  Ex parte Liberty Nat'l
Life Ins. Co., 209 So. 3d 486, 494 (Ala. 2016).
Hendrix points out that both she and United submitted
evidentiary materials in support of, and in opposition to,
United's motion to dismiss.  She also points out that Rule
12(b) provides that, if, on a motion asserting Rule 12(b)(6)
as a defense, "matters outside the pleading [sought to be
dismissed] are presented to and not excluded by the court, the
motion shall be treated as one for summary judgment and
disposed of as provided in Rule 56[, Ala. R. Civ. P.]."  She
asserts that the trial court "should have converted" United's
motion into a summary-judgment motion and allowed her to
conduct discovery pursuant to Rule 56(f), Ala. R. Civ. P.,
which provides:
"Should it appear from the affidavits of a party
opposing the motion [for a summary judgment] that
the party cannot, for reasons stated, present by
affidavit facts essential to justify the party's
opposition, the court may deny the motion for
summary judgment or may order a continuance to
permit affidavits to be obtained or depositions to
be taken or discovery to be had or may make such
other order as is just."
In her opening brief to this Court, Hendrix ignores the
fact that the trial court expressly refused to consider many
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of the materials that had been submitted.  Rather, the trial
court stated that it had considered only documents evidencing
Kenneth's insurance coverage submitted by United, which
included an insurance application, a certificate of coverage,
and a "Large Employer Group Health Contract."    The trial
court expressly stated in its dismissal order that any
consideration it gave the insurance documents did not convert
United's motion to dismiss into a summary-judgment motion
because Hendrix's complaint referenced "United's management
and administration of [Kenneth's] claims for coverage under
the [health-benefit plan]."  The trial court pointed to
Donoghue v. American National Insurance Co., 838 So. 2d 1032,
1035 (Ala. 2002), in which this Court embraced "the
well-founded rule ... precluding conversion [of a motion to
dismiss to a summary-judgment motion] when the exhibits in
question are referred to in, and are central to, the
plaintiff's complaint."  
Before the trial court ruled on United's motion to
dismiss, Hendrix and United took opposing positions as to
whether the motion should be treated as a summary-judgment
motion, and Hendrix specifically argued that the rule adopted
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in Donoghue did not apply.  In her opening brief on appeal,
however, Hendrix ignores the trial court's reliance on
Donoghue and its reasoning regarding the reference in the
complaint to Kenneth's request for benefits under the health-
benefit plan.  She addresses those matters in her reply brief,
arguing that the insurance documents are not "central" to her
claim, but this Court typically will not consider arguments
made for the first time in a reply brief.  Melton v. Harbor
Pointe, LLC, 57 So. 3d 695, 696 n.1 (Ala. 2010).  In any
event, Hendrix's complaint demonstrates that the relationship
between Kenneth and United created by the insurance documents
is what prompted United's actions that, Hendrix claims,
ultimately resulted in a voluntarily assumed duty to provide
medical care.  Without the existence of those documents and
that relationship, United would have played no role at all in
Kenneth's care and could not have been remotely subject to a
claim of medical malpractice.  Based on the arguments before
us, we cannot say that Hendrix has demonstrated that the trial
court erred in concluding that the insurance documents are
central to her claim.5
5Moreover, this Court can determine from Hendrix's
complaint 
alone, 
without 
reference to 
the 
insurance 
documents,
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Discussion
As noted, the federal district court rejected United's
assertion that Hendrix's claim against United is completely
preempted by ERISA.  In a 2009 opinion, the United States
Court of Appeals for the Eleventh Circuit discussed the
distinction 
between 
complete 
preemption 
and 
defensive
preemption and noted that a federal court's decision that a
plaintiff's 
state-law claims 
are 
not 
completely 
preempted 
does
not settle the question whether those claims are defensively
preempted:
"[Defensive preemption under ERISA] is a
substantive defense to preempted state law claims.
Jones v. LMR Int'l, Inc., 457 F.3d 1174, 1179 (11th
Cir. 2006). This type of preemption arises from
ERISA's express preemption provision, § 514(a),
which preempts any state law claim that 'relates to'
an ERISA plan. 29 U.S.C. § 1144(a). ...
"Complete preemption, also known as super
preemption, is a judicially-recognized exception to
the well-pleaded complaint rule. It differs from
defensive preemption because it is jurisdictional in
nature rather than an affirmative defense. Jones,
457 F.3d at 1179 (citing Ervast [v. Flexible Prods.
Co., 346 F.3d 1007, 1014 (11th Cir. 2003)]).
Complete preemption under ERISA derives from ERISA's
civil enforcement provision, § 502(a), which has
such 'extraordinary' preemptive power that it
'converts an ordinary state common law complaint
that her claim against United "relate[s] to" the health-
benefit plan.
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into one stating a federal claim for purposes of the
well-pleaded complaint rule.' [Metropolitan Life
Ins. Co. v. Taylor, 481 U.S. 58, 65-66 (1987)].
Consequently, any 'cause[] of action within the
scope of the civil enforcement provisions of §
502(a) [is] removable to federal court.' Id. at 66.
"Although related, complete and defensive
preemption are not coextensive:
"'Complete preemption is [] narrower than
"defensive" 
ERISA 
preemption, 
which 
broadly
"supersede[s] any and all State laws
insofar as they ... relate to any [ERISA]
plan." ERISA § 514(a), 29 U.S.C. § 1144(a)
(emphasis added). Therefore, a state-law
claim may be defensively preempted under §
514(a) but not completely preempted under
§ 502(a). In such a case, the defendant may
assert preemption 
as a defense, 
but
preemption will not provide a basis for
removal to federal court.'
"Cotton v. Mass. Mut. Life Ins. Co., 402 F.3d 1267,
1281 (11th Cir. 2005); accord Ervast, 346 F.3d at
1012 n. 6 ('Super preemption is distinguished from
defensive 
preemption, 
which 
provides 
only 
an
affirmative defense to state law claims and is not
a basis for removal.')."
Connecticut State Dental Ass'n v. Anthem Health Plans, Inc.,
591 F.3d 1337, 1344 (11th Cir. 2009).  See also Evans v.
Infirmary Health Servs., Inc., 634 F. Supp. 2d 1276, 1292
(S.D. Ala. 2009) ("This Court's holding that plaintiff's
claims are not completely preempted by ERISA resolves the
jurisdictional question, but is not and cannot be dispositive
15
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of [the defendant's] affirmative defense of defensive
preemption.").  
Thus, the federal district court's decision in
this case that United was unable to establish complete
preemption in no way forecloses United from relying on
defensive preemption under § 514(a).6
The preemption language used in § 514(a) is "deliberately
expansive."  Pilot Life Ins. Co., 481 U.S. at 46.  It is aimed
at "'eliminating the threat of conflicting or inconsistent
State and local regulation of employee benefit plans.'"  Id.
at 46 (quoting 120 Cong. Rec. 29197 (1974)).  See also
Egelhoff v. Egelhoff, 532 U.S. 141, 148 (2001) (stating that
a "principal goal[] of ERISA" was "to enable employers 'to
establish a uniform administrative scheme, which provides a
set of standard procedures to guide processing of claims and
disbursement 
of 
benefits'" 
and that 
"[u]niformity 
is
impossible ... if plans are subject to different legal
obligations 
in 
different 
States" 
(quoting 
Fort 
Halifax 
Packing
Co. v. Coyne, 482 U.S. 1, 9 (1987))); Kuhl v. Lincoln Nat'l
6The parties have framed the primary issue before this
Court as whether Hendrix's claim "relates to" an ERISA benefit
plan and is therefore defensively preempted.  We have not been
asked to express an opinion as to the federal district court's
conclusion that Hendrix's claim is not completely preempted. 
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Health Plan of Kansas City, Inc., 999 F.2d 298, 301 (8th Cir.
1993) 
("Consistent 
with 
the 
decision 
to 
create 
a
comprehensive, uniform federal scheme for regulation of
employee benefit plans, Congress drafted ERISA's preemption
clause in broad terms.").
A state law relates to a benefit plan "if it has a
connection with or reference to such a plan."  Shaw v. Delta
Air Lines, Inc., 463 U.S. 85, 97 (1983).  A state law has an
impermissible connection to an ERISA plan if it "'governs ...
a central matter of plan administration' or 'interferes with
nationally 
uniform 
plan 
administration.'"  
Gobeille 
v. 
Liberty
Mut. Ins. Co., ___ U.S. ___, ___, 136 S. Ct. 936, 943 (2016)
(quoting Egelhoff, 532 U.S. at 148).  "'[A] state law may
"relate to" a benefit plan, and thereby be preempted, even if
the law is not specifically designed to affect such plans, or
the effect is only indirect.'"  Weems v. Jefferson-Pilot Life
Ins. Co., 663 So. 2d 905, 908 (Ala. 1995) (quoting
Ingersoll-Rand Co. v. McClendon, 498 U.S. 133, 139 (1990),
quoting in turn Pilot Life Ins. Co., 481 U.S. at 47). 
In Pilot Life Insurance Co., the plaintiff, who had
suffered a back injury at work and had received disability-
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insurance benefits for two years under an ERISA benefit plan,
sued the disability insurer after it terminated his benefits. 
The plaintiff asserted causes of action alleging tortious
breach of contract, breach of fiduciary duty, and fraud in the
inducement.  481 U.S. at 43.  He sought an unspecified amount
of damages "'for failure to provide benefits under the
insurance policy,'" damages for emotional distress, "'other
incidental damages,'" and punitive damages.  Id.  Emphasizing
the expansive sweep of § 514(a), the United States Supreme
Court held that the plaintiff's claims related to an ERISA
plan and were therefore preempted.  In so holding, the Court
stated that "[t]he common law causes of action raised in [the
plaintiff's] complaint, each based on alleged improper
processing of a claim for benefits under an employee benefit
plan, undoubtedly meet the criteria for pre-emption under §
514(a)."  Id. at 48.  See also HealthAmerica v. Menton, 551
So. 2d 235, 239 (Ala. 1989) (describing Pilot Life Insurance
Co. and stating that "claims seeking damages for improperly
processing ... claims for benefits under an ERISA-regulated
plan" are preempted).
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In Davila, the plaintiffs alleged facially state-law
causes of action against the administrators of ERISA-governed
benefit plans after those administrators refused to pay for
treatments that had been recommended by the plaintiffs'
treating physicians.  The plaintiffs' claims were brought
under a Texas statute that imposed a duty on health-insurance
carriers, 
health-maintenance 
organizations, 
and 
other 
managed-
care entities to exercise ordinary care when making health-
care-treatment decisions.  According to the plaintiffs, the
administrators' "refusal to cover the requested services
violated their 'duty to exercise ordinary care when making
health care treatment decisions.'"  542 U.S. at 205.  The
plaintiffs claimed 
they 
had 
suffered 
physical 
injuries 
because
they were unable to obtain the treatments that had been
recommended by their treating physicians.  Similar to
Hendrix's claim in the present case, the plaintiffs in Davila
asserted that the administrators "'controlled, influenced,
participated in and made decisions which affected the quality
of the diagnosis, care, and treatment provided'" the
plaintiffs.  542 U.S. at 212.  The United States Supreme Court
held that the plaintiffs' claims were completely preempted
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because they were aimed at remedying the denial of benefits
under ERISA plans and fell within the scope of ERISA's civil-
enforcement provisions.  Although Davila was a complete
preemption case, it is still helpful in considering whether
Hendrix's claim in the present case "relate[s] to" the health-
benefit plan.  Indeed, the Supreme Court considered an
argument made by the plaintiffs in Davila that their claims
did not "relate to" the ERISA plan involved in that case
because, they argued, the ERISA plan administrators had
exercised judgment regarding proper medical care.  In
addressing that argument, the Court noted that benefit
determinations under ERISA-regulated plans are "part and
parcel 
of 
the 
ordinary 
fiduciary 
responsibilities connected 
to
the administration of a plan," even if those determinations
are "infused with medical judgments."  542 U.S. at 219.  Thus,
the fact that an ERISA plan administrator makes medical
judgments in considering a claim for benefits does not mean
that the administrator has stepped outside its role as an
administrator for purposes of preemption under ERISA.
In Kuhl, supra, Buddy Kuhl, a beneficiary of an ERISA-
governed health plan established by his employer, suffered a
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heart attack.  His treating physician concluded that he needed
heart surgery and that the surgery should be performed at a
hospital in St. Louis, Missouri.  After the surgery was
scheduled, 
the 
health-maintenance 
organization 
("HMO")
responsible for considering and paying claims under the 
health
plan refused to pre-certify payment for the surgery because
the hospital where the surgery was to be performed was outside
the HMO's coverage area.  Later, the HMO determined that it
would indeed pay for the surgery, but, by that time, Kuhl's
condition had deteriorated to the point that the surgery was
not a viable option.  Kuhl died while waiting for a heart
transplant.  His family members sued the HMO, alleging medical
malpractice, tortious interference with Kuhl's right to
contract for medical care, and breach of the contract between
Kuhl's employer and the HMO.  The trial court entered a
summary judgment for the HMO, concluding that the state-law
claims were preempted under § 514(a) of ERISA.  On appeal, the
United States Court of Appeals for the Eighth Circuit affirmed
the summary judgment, stating:
"We have no difficulty in concluding that the
Kuhls' three state law claims that rely on Buddy
Kuhl's status as a beneficiary of the [ERISA plan]
are preempted by ERISA. The Kuhls' claims are all
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based on [the HMO's] alleged misconduct in delaying
Buddy Kuhl's heart surgery in St. Louis. The Kuhls
contend that [the HMO] tortiously interfered with
the contractual relationship between Buddy Kuhl and
his doctors, that [the HMO] committed medical
malpractice because it assumed the role of Buddy
Kuhl's physician by making decisions about proper
medical treatment and made decisions that constitute
medical malpractice, and that [the HMO] breached its
contract with [Kuhl's employer], to which Buddy Kuhl
was a third-party beneficiary, by delaying the
surgery in St. Louis. The district court found that
all of these state law claims arise from the
administration of benefits under the [ERISA plan]
and are therefore preempted by ERISA. We agree."
999 F.2d at 302.  The court continued:
"[The HMO] became involved in the cancellation of
the St. Louis surgery only after the [St. Louis
hospital] staff requested a precertification review.
[The HMO's] admission that it 'cancelled' the
surgery cannot be stretched to imply that [the HMO]
went beyond the administration of benefits and
undertook to provide Buddy Kuhl with medical advice.
Although the surgery in St. Louis was unquestionably
cancelled as a result of [the HMO's] decision not to
precertify payment, the decision not to precertify
payment 
relates 
directly 
to 
[the 
HMO's]
administration of benefits."
999 F.2d at 303.
Hendrix's complaint avers that Kenneth's treating
physician at Gadsden Regional Medical Center determined that
Kenneth needed inpatient rehabilitation and that Kenneth
accepted his doctor's advice.  The complaint also avers that,
at all relevant times, "[Kenneth] had health insurance
22
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coverage that was provided and administered by [United]."  The
complaint then asserts that "Gadsden Regional Medical Center
personnel [and representatives of an inpatient-rehabilitation
facility] all contacted [United] numerous times in an attempt
to get [Kenneth] admitted to an inpatient facility."  The
complaint avers that United refused to authorize inpatient
rehabilitation based on a "medical treatment decision."
It is clear from Hendrix's allegations that the health-
care providers who were actually treating Kenneth contacted
United because United was the administrator of the ERISA-
regulated 
health-benefit 
plan, 
that 
those 
health-care
providers asked United to approve a request for benefits under
that plan, and that Kenneth allegedly died because United
denied all requests for benefits.  Under the wrongful-death
statute, Hendrix seeks to punish United for a death that
allegedly resulted because of a denial of benefits.  Thus, as
United puts it in its brief to this Court, Hendrix's claim
"is, at bottom, '[b]ased on the alleged improper processing of
a claim for benefits'" and, if allowed to proceed, would
"'interfere[] with nationally uniform plan administration.'"
(Quoting  Pilot Life, 481 U.S. at 47-48, and Egelhoff, 532
23
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U.S. at 150.)  Any "medical treatment decision" made by United
was made in its role as the administrator of the health-
benefit plan, not as a health-care provider.  The fact that a
medical judgment is made in the course of denying a request
for benefits does not mean that a cause of action seeking
recovery for an injury or death resulting from that denial
does not "relate to" the relevant ERISA benefit plan. 7
Additional opinions from other jurisdictions, which we
find persuasive, are consistent with our conclusion in this
case.  See Garrison v. Northeast Georgia Med. Ctr., Inc., 66
F. Supp. 2d at 1345 (holding that state-law medical-
7Hendrix suggests throughout her brief that her claim
against United is not defensively preempted because it seeks
to recover punitive damages for wrongful death, not for the
value of benefits under an ERISA plan.  But she misses the
point, since preemption merely requires that her 
claim "relate
to" such a plan.  Hendrix seeks damages based on a death that
allegedly resulted because United denied a request for
benefits under an ERISA-governed plan.  Her claim relates to
that plan regardless of the fact that she seeks only punitive
damages for wrongful death.  Moreover, the Court simply cannot
accept Hendrix's suggestion that her claim is not preempted
because, she says, ERISA would not provide a remedy for
Kenneth's death.  As other courts have recognized, the lack of
a remedy sometimes is an unfortunate consequence of ERISA and
its preemption of state law.  See, e.g., Tolton v. American
Biodyne, Inc., 48 F.3d 937, 943 (6th Cir. 1995) ("One
consequence of ERISA preemption, therefore, is that plan
beneficiaries or participants bringing certain types of state
actions –- such as wrongful death –- may be left without a
meaningful remedy."). 
24
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malpractice action alleging that administrator of an ERISA
plan made a "medical decision" to deny a beneficiary's request
for a particular medical procedure related to an ERISA plan
under § 514(a)); Bast v. Prudential Ins. Co., 150 F.3d 1003
(9th Cir. 1998) (holding that state-law cause of action
alleging that ERISA plan beneficiary died because the plan
administrator delayed approval of a recommended course of
treatment 
based 
on 
the 
administrator's initial 
conclusion 
that
the treatment was "investigational and/or experimental" was
preempted under § 514(a)); Spain v. Aetna Life Ins. Co., 11
F.3d 129 (9th Cir. 1993) (holding that state-law cause of
action against the administrator of an ERISA-regulated plan
that improperly withdrew authorization for a particular
medical procedure, causing plan beneficiary's death, related
to the ERISA plan).
Hendrix points to a pre-Davila case, Pegram v. Herdrich,
530 U.S. 211 (2000), in support of her medical-treatment-
decision argument.  In Pegram, the plaintiff sued her
physician-owned-and-operated HMO, which provided medical
coverage pursuant to an ERISA-regulated benefit plan, after
the plaintiff's doctor, Dr. Lori Pegram, decided not to order
25
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an immediate ultrasound at a local medical facility when she
discovered an inflamed mass in the plaintiff's abdomen. 
Instead, Dr. Pegram ordered that the ultrasound take place
several days later at a different facility staffed by the
HMO's physicians.  The plaintiff claimed that Dr. Pegram's
delay caused her to suffer a ruptured appendix.  The defendant
HMO was owned and operated by a group of doctors that included
Dr. Pegram.  In other words, one of the HMO's physicians was
the plaintiff's treating physician.
Against the HMO, the plaintiff asserted an ERISA breach-
of-fiduciary-duty claim under 29 U.S.C. § 1109, which allows
for such a claim against "[a]ny person who is a fiduciary with
respect to a plan."  The United States Supreme Court, however,
held that the HMO was not an ERISA fiduciary because it had,
through Dr. Pegram, made a "mixed" decision involving both
eligibility under the ERISA plan and the proper course of
medical treatment for the plaintiff.  According to the Court,
"Congress did not intend [an] HMO to be treated as a fiduciary
to the extent that it makes mixed eligibility decisions acting
through its physicians."  530 U.S. at 231.  
26
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Pegram focused on whether a plaintiff could maintain an
ERISA fiduciary claim under 29 U.S.C. § 1109.  It did not
involve preemption.  Some courts, however, relied on its
reasoning in concluding that state-law claims arising from
mixed eligibility and treatment decisions are not preempted. 
For example, in Land v. CIGNA Healthcare of Florida, 339 F.3d
1286 (11th Cir. 2003), the plaintiff commenced a medical-
malpractice claim under state law against the 
administrator of
his ERISA-governed benefit plan after a nurse working for that
administrator refused to approve an extended hospital stay
that had been recommended by the plaintiff's treating
physicians, which the plaintiff claimed resulted in the
eventual amputation of one of his fingers.  Pointing to
Pegram, the United States Court of Appeals for the Eleventh
Circuit held that the malpractice claim was not completely
preempted by ERISA because the nurse had made a "mixed
eligibility and treatment decision."  339 F.3d at 1292. 
However, in Davila, which was decided after Pegram and Land,
the United States Supreme Court stated the 
following regarding
the holding in Pegram:
"Since [ERISA plan] administrators making
benefits determinations, even determinations based
27
1190107
extensively on medical judgments, are ordinarily
acting as plan fiduciaries, it was essential to
Pegram's conclusion that the decisions challenged
there were truly 'mixed eligibility and treatment
decisions,' 530 U.S., at 229, i.e., medical
necessity decisions made by the plaintiff's treating
physician qua treating physician and qua benefits
administrator. Put another way, the reasoning of
Pegram 'only make[s] sense where the underlying
negligence 
also 
plausibly 
constitutes 
medical
maltreatment by a party who can be deemed to be a
treating physician or such a physician's employer.'
Cicio [v. Does, 339 F.3d 83, 109 (2d Cir. 2003)]
(Calabresi, J., dissenting in part). Here, however,
petitioners 
are 
neither 
respondents' 
treating
physicians 
nor 
the 
employers 
of 
respondents'
treating 
physicians. 
Petitioners' 
coverage
decisions, then, are pure eligibility decisions, and
Pegram is not implicated."
542 U.S. at 220–21.  The Eleventh Circuit Court of Appeals'
opinion in Land was vacated by the United States Supreme Court
based on Davila, and the Eleventh Circuit eventually held that
the plaintiff's claims in Land indeed were preempted.  See
Land v. CIGNA Healthcare of Florida, 381 F.3d 1274 (11th Cir.
2004).
There are no facts alleged in the complaint in the
present 
case 
supporting 
Hendrix's 
conclusory assertion that 
an
agent of United voluntarily undertook a duty to act as
Kenneth's treating physician by taking "control" of Kenneth's
treatment or that United made the sort of "mixed eligibility
28
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and treatment" decision the HMO made in Pegram.  The complaint
makes clear that Kenneth's treating physician at the hospital
recommended inpatient rehabilitation and that he applied for
benefits from United to pay for that treatment, but United
denied that request.8
Conclusion
Hendrix's claim relates to an ERISA-governed benefit
plan.  Thus, it is preempted under § 514(a) of ERISA. 
Accordingly, we affirm the trial court's judgment. 9
8Other authority from this Court and the United States
Supreme Court, upon which Hendrix relies, did not involve
preemption of state-law causes of action seeking judgments for
injury or death that resulted because of the denial of ERISA
benefits.  For example, HealthAmerica v. Menton, 551 So. 2d
235 (Ala. 1989), and Ingram v. American Chambers Life
Insurance Co., 643 So. 2d 575 (Ala. 1994), involved claims
alleging that the plaintiffs were fraudulently induced to
purchase ERISA-governed insurance policies.  New York State
Conference of Blue Cross & Blue Shield Plans v. Travelers
Insurance Co., 514 U.S. 645 (1995), involved whether ERISA
preempted a state statute imposing a surcharge on hospital
patients who had insurance coverage provided by an insurer
other than Blue Cross/Blue Shield.
9Hendrix relies on opinions that, she says, demonstrate
the existence of a presumption against ERISA preemption of
state-law causes of action.  For its part, United points to
the 2016 opinion of the United States Supreme Court in Puerto
Rico v. Franklin California Tax-Free Trust, ___ U.S. ___, 136
S.Ct. 1938 (2016), for the proposition that the Court rejected
any presumption against preemption when dealing with express
preemption provisions.  Hendrix responds that Puerto Rico
involved an express preemption provision in a bankruptcy
29
1190107
AFFIRMED. 
Bolin and Mendheim, JJ., concur.
Shaw and Bryan, JJ., concur in the result.
Parker, C.J., and Wise and Stewart, JJ., dissent.
Mitchell, J., recuses himself.
statute, not ERISA.  We note that other courts have refused to
limit the Puerto Rico holding on that issue to cases involving
bankruptcy law.  See Dialysis Newco, Inc. v. Community Health
Sys. Grp. Health Plan, 938 F.3d 246, 258 (5th Cir. 2019)
(applying Puerto Rico's rejection of a presumption against
preemption to ERISA and noting that other courts have not
limited Puerto Rico to bankruptcy cases).  In any event,
assuming there is a presumption against preemption under §
514(a) of ERISA, the trial court did not err in concluding
that United has overcome it.  We have no doubt that Hendrix's
claim against United "relate[s] to" an ERISA plan within the
meaning of § 514(a).
30
1190107
SHAW, Justice (concurring in the result).
I concur in the result.  I am not convinced that the
preemption provided by 29 U.S.C. § 1144(a) bars a wrongful-
death action in circumstances where an insurance company,
allegedly acting to administer a health-benefit plan, in fact
assumes medical care of its insured and by that action causes
the death of the insured.  However, after reviewing the
particular complaint at issue in this case, I am not persuaded
that, for the purpose of reviewing the trial court's entry of
a dismissal under the applicable Rule 12(b)(6), Ala. R. Civ.
P., standard of review, such preemption can be avoided.
Bryan, J., concurs. 
31
1190107
PARKER, Chief Justice (dissenting). 
I believe the plurality opinion strays from the language
of ERISA.10  The crux of that opinion is that "Hendrix's claim
relates to an ERISA-governed benefit plan" and therefore "is
preempted under [§ 1144(a)] of ERISA." But a closer
examination of the text of 29 U.S.C. § 1144 makes that
conclusion far from obvious.  That text provides that specific
ERISA enforcement provisions supersede certain state laws. 
Thus, any conclusion that ERISA preempts a state-law claim,
without reference to those provisions, is problematic.  And it
is not at all apparent to me that the enforcement scheme
embodied in those provisions supplants an Alabama wrongful-
death claim against an ERISA administrator. 
Defensive preemption is a product of 29 U.S.C. § 1144(a):
"[T]he provisions of ... subchapter [I] and subchapter III [of
ERISA] shall supersede any and all State laws insofar as they
... relate to any [ERISA-governed] employee benefit plan ...."
Section 1132, ERISA's civil-enforcement provision located in
subchapter I, creates rights of action in plan beneficiaries
and participants, the Secretary of Labor, plan fiduciaries,
10The Employee Retirement Income Security Act of 1974, 29
U.S.C. § 1001 et seq.
32
1190107
and employers. 29 U.S.C. § 1132(a). Notably, the civil-
enforcement provision does not mention claims by third
parties; it does not create or expressly abrogate any third-
party right of action.   
Consistent with this focus of subchapter I, cases in
which this Court has found § 1144(a) defensive preemption
involved claims by a beneficiary to enforce rights under a
policy or to compensate for harm resulting from an insurer's
improper administration of a policy.  See Seafarers' Welfare
Plan v. Dixon, 512 So. 2d 53, 54–55 (Ala. 1987) (explaining
that a life-insurance beneficiary's "state common law causes
of action claiming benefits under an employee benefit plan
regulated by ERISA [were] preempted by ERISA, and that the
proper recourse [was] to utilize the civil enforcement
provisions of ERISA"); Weems v. Jefferson-Pilot Life Ins. Co.,
663 So. 2d 905, 909 (Ala. 1995) (beneficiaries' claims for
breach of contract, bad faith, fraud, negligence, wantonness,
and willfulness); Landy v. Travelers Ins. Co., 530 So. 2d 214,
215 (Ala.  1988) (beneficiary's breach-of-contract claim);
Hood v. Prudential Ins. Co. of Am., 522 So. 2d 265 (Ala. 1988)
33
1190107
(beneficiary's claim alleging bad-faith refusal to pay
insurance benefits).  
In contrast, this Court has recognized that § 1144(a)
does not preempt certain claims that merely tangentially
implicate a 
beneficiary's 
rights. 
See 
HealthAmerica v. 
Menton,
551 So. 2d 235, 238 (Ala. 1989) ("We hold that a
[beneficiary's] claim for fraud in the inducement [based on an
insurer's misrepresentation about policy benefits] does not
'relate to' an employee benefit plan and is therefore not
preempted by ERISA."); see also Ingram v. American Chambers
Life Ins. Co., 643 So. 2d 575, 577 (Ala. 1994) (disagreeing
with 
defendant's 
argument 
that 
Weems 
repudiated
HealthAmerica). In particular, § 1144(a) does not preempt a
third-party claim against an insurer where the claim does not
seek benefits under the policy. See Brookwood Med. Ctr. v.
Celtic Life Ins. Co., 637 So. 2d 1385 (Ala. Civ. App. 1994)
(holding that ERISA did not preempt state-law claims of
third-party health-care provider against employee-benefit
provider based on negligent misrepresentation of coverage). 
As the Court of Civil Appeals explained in Brookwood: "ERISA
preempts a state law cause of action brought by an ERISA plan
34
1190107
participant or beneficiary alleging improper processing of a
claim for plan benefits," id. at 1387, but
"'[c]ourts are more likely to find that a state law
relates to a benefit plan if it affects relations
among the principal ERISA entities -- the employer,
the 
plan, 
the 
plan 
fiduciaries, 
and 
the
beneficiaries –- than if it affects relations
between one of these entities and an outside party,
or between two outside parties with only an
incidental effect on the plan.'"
Id. (quoting Sommers Drug Stores Co. Emp. Profit Sharing Trust
v. Corrigan Enters., Inc., 793 F.2d 1456, 1467 (5th Cir.
1986)).  
In a similar vein, the United States Supreme Court has
contrasted "civil enforcement actions ... to secure specified
relief, including the recovery of plan benefits," with
"lawsuits against ERISA plans for run-of-the-mill state-law
claims such as ... torts committed by an ERISA plan." Mackey
v. Lanier Collection Agency & Serv., Inc., 486 U.S. 825, 833
(1988).  ERISA preempts the former but not the latter.  Id.  
An Alabama wrongful-death claim of the kind alleged here
does not seek to enforce a beneficiary's rights under a policy
or seek compensation for a beneficiary for harm from improper
plan 
administration.  
The 
wrongful-death statute 
provides 
that
35
1190107
"[a] personal representative may commence an action
and recover ... damages ... for the wrongful act,
omission, or negligence of any ... corporation ...
or [its] servants or agents, whereby the death of
the testator or intestate was caused, provided the
testator or intestate could have commenced an action
for the wrongful act, omission, or negligence if it
had not caused death."
§ 6-5-410, Ala. Code 1975. The claim is brought by a third
party, a personal representative, who essentially acts as the
State's agent and not as the agent of a beneficiary. Moreover,
the statute does not compensate the decedent's estate for the
decedent's death; rather, the statute is punitive and
deterrent, creating a new right of action in the personal
representative. In 
effect, 
the 
personal 
representative acts 
as
the State's agent to punish the wrongful killing of the
decedent and to deter conduct that tends to lead to wrongful
deaths. See Deaton, Inc. v. Burroughs, 456 So. 2d 771, 776
(Ala. 1984) ("In a wrongful death action ..., the only damages
recoverable are punitive in nature, and the amount thereof is
determined by the gravity of the wrong done, the propriety of
punishing the wrongdoer, and the need for deterring others
from committing the same or similar wrongful conduct."); 1
Alabama Personal Injury and Torts § 9:6 (2020) ("The Wrongful
Death Act creates the right in the personal representative of
36
1190107
the decedent to act as agent by legislative appointment for
the effectuation of a legislative policy of the prevention of
homicides through the deterrent value of the infliction of
punitive 
damages.").11 
Notably, 
Alabama 
is 
the 
only 
state 
whose
11This 
Court 
recently 
reiterated 
its 
historically
consistent position that Alabama's wrongful-death statute is
noncompensatory:
"'This statute authorizes suit to be brought by
the 
personal 
representative 
for 
a 
definite
legislative purpose -- to prevent homicide. In
prosecuting 
such 
actions, 
the 
personal
representative does not act strictly in his capacity
as administrator of the estate of his decedent,
because he is not proceeding to reduce to possession
the estate of his decedent, but rather he is
asserting a right arising after his death, and
because the damages recovered are not subject to the
payment of the debts or liabilities of the decedent.
He 
acts 
rather 
as 
an 
agent 
of 
legislative
appointment for the effectuation of the legislative
policy.... And the right is vested in the personal
representative alone.'"
Pollard v. H.C. P'ship, [Ms. 1180795, March 13, 2020] ___ So.
3d ___, ___ (Ala. 2020) (quoting Hatas v. Partin, 278 Ala. 65,
67–68, 175 So. 2d 759, 761 (1965)). Elaborating in his special
concurrence, Justice Bolin explained further:
"The legislature created a remedy for the wrongful
death of a human being, the stated purpose being to
deter homicide by the imposition of punitive
damages; no benefits of this remedy would inure to
the benefit of the decedent's estate but, rather,
would be prosecuted by a trustee, whom the
legislature 
determined 
to 
be 
the 
personal
representative, for the benefit of the decedent's
heirs at law ...."
37
1190107
wrongful-death statute is noncompensatory.  2 Trial Handbook
for 
Alabama 
Lawyers 
§ 
38:23 
(3d 
ed. 
2020). 
This
noncompensatory nature distinguishes the statute from other
states' wrongful-death statutes that courts have held are
defensively preempted by § 1144(a). See Garrison v. Northeast
Georgia Med. Ctr. Inc., 66 F. Supp. 2d 1336 (N.D. Ga. 1999);
Bast v. Prudential Ins. Co., 150 F.3d 1003 (9th Cir. 1998);
Spain v. Aetna Life Ins. Co., 11 F.3d 129 (9th Cir. 1993). 
In this case, it is clear that United Healthcare
Insurance Company of the River Valley ("United") seeks to
extend defensive preemption to a different kind of claim from
those that ERISA plainly preempts.  In my view, United and the
plurality opinion have not established a clear statutory
indication that defensive preemption applies to this claim.
Wise, J., concurs.
  
   
Id. at ___.
38