Opinion ID: 4517940
Heading Depth: 2
Heading Rank: 3

Heading: Applying Humble

Text: To avoid the dispositive effect of Humble, North Cypress proposes four critiques: Humble contradicts North Cypress I and lacks authority; Kennedy, on which Humble relied, is inapplicable to this case; Cigna did not rely on Kennedy in this case; and various facts render Humble distinguishable. These are meritless. First, it is simply incorrect to claim that “Humble came to a different conclusion than did N. Cypress finding that Cigna’s Exclusion interpretation is ‘legally correct.’” Humble came to no such conclusion. Instead, the court “skip[ped]” consideration of the issue because “even if [Cigna’s] construction of the plans’ exclusionary language was legally incorrect, its interpretation still fell within its broad discretion.” Humble, 878 F.3d at 484. Moreover, North Cypress I made no final determination about the legal correctness of Cigna’s interpretation, as it merely “suggested (without deciding) that this reading might be legally incorrect.” 9 Id. Humble remains binding. North Cypress contends that here, unlike in Kennedy, North Cypress left patients legally responsible for co-payments. True or not, that contention is 9It stated that “[t]here are strong arguments” for that conclusion, declined to rule for Cigna on the merits of North Cypress’s ERISA claims, and vacated the district court’s summary judgment on North Cypress’s state contract law claims, in which the district court had determined that Cigna’s interpretation was legally correct. In vacating that holding, the panel characterized it as “filtered through state contract law and based on a much smaller universe of claims” than would be a final decision on the ERISA claims. 781 F.3d at 196–97. 11 Case: 18-20576 Document: 00515350925 Page: 12 Date Filed: 03/19/2020 No. 18-20576 irrelevant for present purposes. Humble relied on Kennedy, not to determine whether patients actually were responsible for co-payments, but rather to determine whether Cigna reasonably required that patients be legally responsible for co-payments. Humble, 878 F.3d at 484–85. As North Cypress admits, the relevant interpretation in this case is the same as the interpretation in Humble. Kennedy was reasonably invoked in Humble in determining whether Cigna’s interpretation was an abuse of discretion, and it is reasonably applicable here. North Cypress counters that, even if Kennedy applies to this case, Cigna did not rely on Kennedy. Indeed, a series of “facts here not present in Humble” 10 constitute Cigna’s alleged conflicts of interest and lack of good faith. As previously explained, however, they are immaterial. Finally, North Cypress does not adequately brief a challenge to the existence of substantial evidence supporting Cigna’s decisions. 11 Even if a plan 10 North Cypress alleges that (1) Cigna mobilized a team to pressure North Cypress to join its provider network, (2) this team invented an approach that involved making reduced payment, if any, to North Cypress and convincing plan sponsors to reduce reimbursement of North Cypress, (3) Cigna created the Protocol “exclusively for North Cypress, not relying on Kennedy,” (4) Cigna repeatedly stated a goal to force North Cypress to the negotiating table to enter an in-network contract, (5) North Cypress reversed its Prompt Pay Discount and billed thousands of patients the full amount of their out-of-network responsibility after the patients failed to pay timely, (6) North Cypress did not commit fraud or provide “kickbacks,” and (7) “Cigna used North Cypress as a pretext to plan sponsors for payments based on billed charges from 2007-12 to make millions in additional ‘contingency fees.’” 11 In this case, the district court ruled that substantial evidence supported Cigna’s conclusion. North Cypress, in its initial brief, notes as a fact in its “Statement of the Case,” that “only the original 27 ‘modest’ surveys were Cigna’s foundation to adjudicate 9,921 North Cypress claims as ‘fee-forgiving’ on a patient responsibility of $100.” Also, North Cypress (erroneously) faults the district court for failing to consider whether Cigna had substantial evidence for its decision, and, in the course of arguing about the district court’s damages rulings, it notes that the district court’s ruling “rel[ied] on . . . the erroneous finding of ‘substantial evidence’ to support Cigna’s actions.” At no point in its initial brief, however, does North Cypress provide an argument against the district court’s finding of substantial evidence. 12 Case: 18-20576 Document: 00515350925 Page: 13 Date Filed: 03/19/2020 No. 18-20576 interpretation is not an abuse of discretion, particular benefit decisions must be supported by substantial evidence. Humble, 878 F.3d at 485. With this failure, no grounds remain on which to find that Cigna abused its discretion. North Cypress’s ERISA § 502 claims fail.