Opinion ID: 4549171
Heading Depth: 3
Heading Rank: 4

Heading: The Center’s Unjust Enrichment Claims

Text: We reach the opposite conclusion for the Center’s unjust enrichment claims, which we hold do entail an impermissible “reference to” the ERISA plans. To establish a claim of unjust enrichment under New Jersey law, the Center must demonstrate that Aetna “received a benefit and that retention of that benefit without payment would be unjust.” Thieme v. Aucoine-Thieme, 151 A.3d 545, 557 (N.J. 2016) (citation omitted). The Center must also show “that it expected remuneration from [Aetna] at the time it performed or conferred [that] benefit on [Aetna] and that the failure of remuneration enriched [Aetna] beyond its contractual 40 rights.” Id. (citation omitted). No unjust enrichment claim may proceed absent a showing of a benefit—indeed, “the basis of liability [for an unjust enrichment claim] springs from the benefit conferred.” St. Paul Fire & Marine Ins. Co. v. Indemnity Ins. Co. of N. Am., 158 A.2d 825, 827 (N.J. 1960) (citation omitted); see Callano v. Oakwood Park Homes Corp., 219 A.2d 332, 334 (N.J. Super. Ct. App. Div. 1966). Given those elements, whether a given unjust enrichment claim is preempted may turn on the nature of the benefit: The claim will be preempted if that benefit “is premised on . . . the existence of a[n ERISA] plan,” Ingersoll-Rand, 498 U.S. at 140, or if “the existence of ERISA plans is essential to the law’s operation,” Gobeille, 136 S. Ct. at 943 (quoting Cal. Div. of Labor Standards Enf’t v. Dillingham Constr., N.A., 519 U.S. 316, 325 (1997)). Put differently, if “the court must find . . . that an ERISA plan exists,” Ingersoll-Rand, 498 U.S. at 140, to establish that element, such that “there simply is no cause of action if there is no plan,” id., then “the court’s inquiry must be directed to the plan,” and “this . . . cause of action ‘relate[s] to’ an ERISA plan,” id. (second alteration in original) (citation omitted). Here, the “benefit conferred” is indeed premised on the existence of the plan. That is because in a case like the Center’s, where a healthcare provider claims unjust enrichment against an insurer, the benefit conferred, if any, 26 is not the 26 We note that district judges in New Jersey have disagreed over whether a healthcare provider’s provision of services to an insured may ever constitute a “benefit” to an insurer for purposes of an unjust enrichment claim. Compare Plastic Surgery Ctr., LLC v. Oxford Health Ins., Inc., No. 18-cv-2608, 41 provision of the healthcare services per se, but rather the discharge of the obligation the insurer owes to its insured. As New Jersey’s highest court observed long before the advent of ERISA, the essence of an unjust enrichment cause of action against an insurer is that “the [insurer] is under a legal duty to provide the person injured with medical or surgical attendance,” and “the physician . . . dutifully intervene[d] in the [insurer’s] affairs and perform[ed] its obligation.” Rabinowitz v. Mass. Bonding & Ins. Co., 197 A. 44, 47 (N.J. 1938) (citation omitted). And the Center’s own complaint— describing the benefits at issue as “permitting Aetna to fulfill its contractual obligation to D.W. to pay for medically 2019 WL 4750010, at –6 (D.N.J. Sept. 30, 2019) (concluding that a healthcare provider may not bring an unjust enrichment claim against an insurer because the “benefit is derived solely by the insured party” (citation omitted)), with Demaria v. Horizon Healthcare Servs., Inc., No. 2:11-cv-7298, 2013 WL 3938973, at  (D.N.J. July 31, 2013) (allowing an unjust enrichment claim brought by a healthcare provider against an insurer to proceed). Those that have held the benefit lies solely with the insured have done so in reliance upon the reasoning of Travelrs Indemnity Co. of Connecticut v. Losco Group, Inc., 150 F. Supp. 2d 556 (S.D.N.Y. 2001), specifically that “[i]t is counterintuitive to say that services provided to an insured are also provided to its insurer,” id. at 563. Travelers Indemnity, however, dealt with a claim of quantum meruit, not a claim of unjust enrichment, id. at 562, and its reasoning is at odds with the decisions of the New Jersey state courts that have allowed these types of unjust enrichment claims to proceed. See, e.g., Rabinowitz v. Mass. Bonding & Ins. Co., 197 A. 44, 46–47 (N.J. 1938). 42 necessary surgeries,” JA 61, and allowing Aetna to “fulfill[] [its] contractual obligation to J.L.,” JA 204—makes plain that this is its theory. What it fails to appreciate, however, is that in the modern era, when the insured is a plan participant, the “contractual obligation” is none other than the insurer’s duty to its insured under the terms of the ERISA plan. That point was not lost on the Fifth Circuit when it distinguished in Access Mediquip between the provider’s state law misrepresentation claim— which was based on a law that “d[id] not purport to regulate what benefits [the insurer] provides to the beneficiaries of its ERISA plans, but rather what representations it makes to third parties about the extent to which it will pay for their services,” 662 F.3d at 385—and its unjust enrichment claim, for which the provider could recover “only to the extent that the patients’ ERISA plans confer on their participants and beneficiaries a right to coverage for the services provided,” 27 id. at 386. And 27 The Access Mediquip court reached the same conclusion as to the provider’s claim of quantum meruit, 662 F.3d at 386– 87, although it is unclear how the analysis would bear out, at least with respect to the “reference to” part of the express preemption test, under New Jersey law which does not require a showing of a benefit conferred to establish a quantum meruit claim. See Starkey, Kelly, Blaney & White v. Estate of Nicolaysen, 796 A.2d 238, 242–43 (N.J. 2002) (recovery under a quantum meruit claim requires “(1) the performance of services in good faith, (2) the acceptance of the services by the person to whom they are rendered, (3) an expectation of compensation therefor, and (4) the reasonable value of the services.” (citation omitted)). 43 the Eighth, Ninth, Tenth, and Eleventh Circuits likewise have recognized that a misrepresentation claim brought by a thirdparty healthcare provider, given its legal basis independent of the ERISA plan, is not necessarily preempted. See In Home Health, 101 F.3d at 605–07; Meadows, 47 F.3d at 1009–11; Hospice of Metro Denver, 944 F.2d at 755–56; Lordmann, 32 F.3d at 1533–34; cf. Iola, 700 F.3d at 84–85 (holding a misrepresentation claim preempted based on statements that occurred after the participants had entered into an ERISA plan but allowing a misrepresentation claim based on statements made before the participants had entered into the plan to proceed). That distinction is no less important here. To put a fine point on it, Aetna’s duties to J.L. and D.W. appear to arise specifically from plan provisions stating that “[i]f Aetna refers [the insured] to a Non-Network provider, the service or supply shall be covered as a network service or supply,” JA 108 (D.W.’s plan); accord JA 248 (J.L.’s plan) (similar), and that “Aetna is fully responsible for payment to the health care professional and the [insured]’s liability shall be limited to any applicable Network Copayment, Coinsurance or Deductible for the service or supply,” JA 108; accord JA 248 (similar). Thus, unlike the Center’s claims of breach of contract or promissory estoppel, which seek to enforce a promise of payment independent of any plan-based obligation, see supra at pages 16–35, its unjust enrichment claims require “the court [to] find . . . that an ERISA plan exists,” Ingersoll-Rand, 498 U.S. at 140, in order to demonstrate that Aetna “received a benefit”—i.e., the discharge of its duties under that plan—“and that retention of that benefit without payment would be unjust,” Thieme, 151 A.3d at 557 (citation omitted). Likewise, because the benefit involves a plan-based duty, “there simply 44 is no cause of action [for unjust enrichment] if there is no plan.” Ingersoll-Rand, 498 U.S. at 140. This claim is thus squarely preempted by section 514(a).