Opinion ID: 613077
Heading Depth: 4
Heading Rank: 1

Heading: The Reasoning in the Glover Case and the Unanswered Questions It Raises

Text: The facts and procedural history in Glover are relatively simple. Two individuals filed a lawsuit against two major tobacco companies under the Medicare Secondary Payer Act's private cause of action. 459 F.3d at 1306-07. The plaintiffs, seeking to act as private attorneys general, sued to recover for the Medicare program all the expenditures it made [over an eight-year period] for health care services rendered in the State of Florida to Medicare beneficiaries for the treatment of diseases attributable to cigarette smoking. Id. at 1307. In other words, the plaintiffs sought first to use the Act to establish the tobacco companies' state-law tort liability for battery and, then, to recover reimbursement for payments made by Medicare. Id. Notably, the plaintiffs did not allege that the tobacco companies caused them any personal harm: they did not allege that they were smokers themselves, or that the defendants' refusal to pay for medical treatment forced them to foot the bill. After the district court dismissed their lawsuit for failure to state a claim, the Eleventh Circuit affirmed, citing both the demonstrated responsibility provision and a fear that a contrary holding would greatly expand federal jurisdiction over state-law tort cases. Id. at 1308-09. It is the Glover opinion's discussion of the demonstrated responsibility provision that has precipitated the current state of the law. Its reasoning arose from a valiant attempt to make sense of the conjunction in the Act's private cause of action, which creates liability against primary plans who fail to pay for treatment in accordance with paragraphs (1) and (2)(A). Id. § 1395y(b)(3)(A). But as discussed above in Part III.A, a primary plan cannot violate subparagraph (2)(A), which is addressed exclusively to Medicare, not to primary plans. Rather than digging this deeply into the statute, however, the Glover case reasoned that subparagraph (2)(A) mentions subparagraph (2)(B), that buried within subparagraph (2)(B) is sub-subparagraph (2)(B)(ii), and that sub-subparagraph (2)(B)(ii) places a condition on when a primary plan must reimburse Medicare for a conditional payment made by Medicare: a primary plan must reimburse Medicare only if its responsibility to pay for the treatment has already been demonstrated. See Glover, 459 F.3d at 1308-09. Accordingly, the Glover case reasoned, a primary plan cannot fail to pay in accordance with paragraph[] ... (2)(A)  and, thus, cannot be liable under the private cause of action  unless its responsibility to pay for the treatment has been demonstrated prior to the litigation. Id. at 1308-09. As for how a primary plan's responsibility must be demonstrated, Glover pointed to the next sentence of sub-subparagraph (2)(B)(ii): A primary plan's responsibility ... may be demonstrated by a judgment, a payment conditioned upon the recipient's compromise, waiver, or release (whether or not there is a determination or admission of liability) of payment for items or services included in a claim against the primary plan or the primary plan's insured, or by other means. This reasoning raises several questions, all left unanswered. First, why would Congress include a private cause of action within a statutory scheme but then limit its use to situations in which the defendant's liability has already been legally demonstrated? Assuming that a primary plan's responsibility to pay is generally demonstrated by a judgment, then the private cause of action (with its provision for double damages) is morphed into a super-judgment enforcement mechanism: when a primary plan is adjudged liable under the ERISA laws but obstinately refuses to pay the judgment, the plaintiff can file a new cause of action so that the primary plan is really forced to pay. But why would Congress think such an unusual mechanism to be necessary here? Why is the typical judicial process for executing judgments insufficient? No answer is given from Glover, Central States, or the Act's sparse legislative history. Second, why would Congress choose to limit so severely the Act's only private cause of action through a sentence buried multiple subparagraphs away, especially when that sentence is contained in a sub-subparagraph that is not directly referenced in the private cause of action's text? No answer. Third, how can the demonstrated responsibility provision limit the liability of a primary plan to a private party when the text of that provision only places a condition on when primary plans must pay Medicare, not private parties? No answer.