Opinion ID: 2422265
Heading Depth: 1
Heading Rank: 5

Heading: Davila Prong One: Step Two

Text: We turn to the second step of the first prong of the Davila testwhether the actual claims that Montefiore asserts can be construed as colorable claims for benefits pursuant to § 502(a)(1)(B). See Firestone Tire & Rubber Co., 489 U.S. at 117-18, 109 S.Ct. 948. Montefiore argues, and defendants deny, that its claims are simply contract and quasi-contract claims that have nothing to do with ERISA, and cannot be construed as claims for benefits under the Plan. Specifically, Montefiore contends, inter alia, that the central disputed issue in this case is the amount which the Fund was required to pay Montefiore, pursuant to its contractual obligations to Montefiore. To this end, Montefiore emphasizes a common distinction in the case law between claims involving the right to payment and claims involving the amount of paymentthat is, on the one hand, claims that implicate coverage and benefits established by the terms of the ERISA benefit plan, and, on the other hand, claims regarding the computation of contract payments or the correct execution of such payments. The former are said to constitute claims for benefits that can be brought pursuant to § 502(a)(1)(B), while the latter are typically construed as independent contractual obligations between the provider and the PPO or the benefit plan. See, e.g., Lone Star OB/GYN Assocs. v. Aetna Health Inc., 579 F.3d 525, 530-31 (5th Cir.2009); Pascack Valley Hosp., Inc., 388 F.3d at 403-04; Blue Cross of Cal. v. Anesthesia Care Assocs. Med. Grp., 187 F.3d 1045, 1051 (9th Cir. 1999). This distinction is helpful and instructive; however, after applying it to the claims for reimbursement submitted by Montefiore, the result is not favorable to Montefiore's argument on appeal. For example, among the selection of claims for reimbursement that the parties specifically submitted for our attention on appeal, [11] all of those for which the reason for denial is discernible [12] appear to implicate coverage determinations under the relevant terms of the Plan, including denials of reimbursement because pre-certification [is] required, because the services [were] not covered under [the] plan, or because the member is not eligible. Joint App'x at 293, 296, 303. None of the selected claims appear to be claims regarding, for example, underpayment or untimely payment, where the basic right to payment has already been established and the remaining dispute only involves obligations derived from a source other than the Plan. [13] In the proceedings below, the District Court analyzed the claim forms, reviewed related affidavits and evidence, and subsequently held in its Opinion & Order that the Fund refused payment on at least some, if not all, of Montefiore's claims because certain services were not covered by the Plan, patients were not eligible under the Plan, or Montefiore neglected to follow procedures as set forth in the Plan. We conclude that it was proper for the District Court to look beyond the mere allegations of the complaint to the claims themselves (including supporting documentation) in conducting its analysis, and we agree with the District Court's conclusion that these claims are colorable claims for benefits pursuant to ERISA § 502(a)(1)(B).
Under Davila, a claim is completely preempted only if there is no other independent legal duty that is implicated by [the] defendant's actions. 542 U.S. at 210, 124 S.Ct. 2488. The key words here are other and independent. As noted above, at least some of the claims at issue here are benefits claims in character ( i.e., they are right to payment claims). Accordingly, the right to payment forms the ERISA-related basis for legal action regarding those claims for reimbursement, and the only question remaining is whether some other, completely independent duty forms another basis for legal action (if the claims were in fact merely about the rate or execution of payment, they would not present a colorable claim pursuant to § 502(a)(1)(B) and we would not need to reach the application of the second prong of Davila ). Here, apart from Montefiore's argument that its claims involve only the amount of payment, Montefiore asserts that its claims sound separately and independently in quasi-contract law. See Appellant's Br. at 44-46. Specifically, Montefiore argues that prior to providing services to each beneficiary, it would call the Fund and verify that the patient was eligible and that the anticipated services were covered. These verbal communications, Montefiore contends, gave rise to an independent legal duty between Montefiore and the Fund. We are not persuaded. Whatever legal significance these phone conversations may have had, see Appendix A, they did not create a sufficiently independent duty under Davila indeed, as Montefiore concedes, this pre-approval process was expressly required by the terms of the Plan itself and is therefore inextricably intertwined with the interpretation of Plan coverage and benefits.