Opinion ID: 4549171
Heading Depth: 5
Heading Rank: 1

Heading: The claims plausibly seek to enforce

Text: obligations independent of the plan Whether the Center seeks to enforce obligations independent of the plan turns on whether the parties agreed (i) that Aetna would provide payment for all services necessary to perform the respective surgeries, leaving only the amount of payment pegged to the terms of the plan; or (ii) that the scope 20 of coverage, as well as payment, would be limited to the terms of the plans—leaving open the possibility that some services would not be compensated at all. Aetna argues the latter, relying on Pilot Life Insurance Co. v. Dedeaux, 481 U.S. 41, 48 (1987), Menkes, 762 F.3d at 295– 96, and Kollman, 487 F.3d at 150. But those cases are inapposite. The common law claims in each were brought by plan participants or beneficiaries, alleging either that the insurer or plan administrator, or an agent thereof, had improperly processed or misrepresented the benefits due under the plan. Pilot Life, 481 U.S. at 43–44, 48; Menkes, 762 F.3d at 294–96; Kollman, 487 F.3d at 150. Those plaintiffs sought to enforce legal obligations flowing from the four corners of their ERISA plans. The claims here, on the other hand, arose precisely because there was no coverage under the plans for services performed by an out-of-network provider like the Center. In contrast to in-network providers whose relationship with Aetna is governed by a provider agreement that typically crossreferences the ERISA plan and limits payment to “covered services,” defined as those claims recognized as “medically necessary” under the terms of the relevant ERISA plan, see, e.g., Lone Star OB/GYN Assocs. v. Aetna Health Inc., 579 F.3d 525, 530 (5th Cir. 2009), out-of-network providers do not have pre-existing contractual relationships with the insurer. Thus, absent a separate agreement between Aetna and the Center, there was no obligation for the Center to provide services to the plan participants, no obligation for Aetna to pay the Center for its services, and no agreement that compensation would be 21 limited to benefits covered under the plan. 16 And the complaints allege such separate agreements here: As pleaded, the parties agreed that the Center would perform the surgeries and related medical care in exchange for payment from Aetna of a “reasonable amount” under J.L.’s plan and at the “highest in[-]network level” under D.W.’s plan for all component services (not merely those services covered under the terms of the plan). JA 59, 201–02. 16 We offer no opinion on the circumstances in which innetwork providers could bring state law claims for breach of contract arising out of the provider agreement or an equitable cause of action, such as promissory estoppel or quantum meruit, arising out of an insurer’s promise of payment without running afoul of section 514(a), which would depend on the content of the claims and the terms of the provider agreement. See, e.g., Pascack, 388 F.3d at 403; Kolbe & Kolbe Health & Welfare Benefit Plan v. Med. Coll. of Wis., Inc., 657 F.3d 496, 504–05 (7th Cir. 2011); Lone Star, 579 F.3d at 530; Blue Cross, 187 F.3d at 1050–54. Nor do we suggest that out-of-network providers are categorically exempt from section 514(a), with carte blanche to file suit for services rendered to plan participants. See, e.g., Access Mediquip, 662 F.3d at 386–87 (holding section 514(a) preempts unjust enrichment and quantum meruit claims premised on obligations imposed by ERISA plans rather than an independent promise of payment). Whether any agreement was reached with a provider, and the extent to which the terms of that agreement are so intertwined with the plan as to “relate to” an ERISA plan, are questions that depend on the facts and circumstances of the given case. 22 Aetna’s argument that the Center agreed to be bound by all terms and conditions of the plan—in effect, that it agreed to be paid as if it were an in-network provider—is simply not apparent on the face of the pleadings. In the case of J.L., the Center alleges that “Aetna contracted with [the Center] to provide multi-stage breast reconstruction surgery to J.L., along with related medical services, and to pay [the Center] a reasonable amount for those services according to the terms of the Plan.” JA 201–02. Accepting the pleadings as true and drawing all inferences in the Center’s favor, as we must at the motion to dismiss stage, we conclude that only the amount of payment and not the scope of services was to be determined in accordance with the terms of the plan; the services agreed to be compensated were all those required to perform J.L.’s procedure. The same holds true in D.W.’s case. We may reasonably infer from notes attached to the complaint that the Center identified at least eighteen distinct CPT 17 codes associated with D.W.’s surgery; the Center also alleges that a Center employee faxed D.W.’s clinical information to Aetna, requesting a “single case agreement” and was assured that if Aetna agreed to pay for the procedure it would instead pay the Center “at the highest in[-]network level,” JA 65, 67 (capitalization altered); and the Center alleges that an Aetna employee subsequently called the Center to confirm that Aetna “had agreed to approve 17 “CPT” stands for “Current Procedural Terminology” and is defined in D.W.’s plan as “the most recent edition of an annually revised listing published by the American Medical Association which assigns numerical codes to procedures and categories of medical care.” JA 81. 23 and pay” for the procedure, JA 59. These allegations plausibly support the inference that Aetna agreed to pay for all component services of D.W.’s surgery at the highest innetwork level. Aetna points to other evidence supporting a contrary inference. For example, it highlights the portion of the notes reflecting that it “do[es]n’t neg[otiate] [single case agreements] an[y] longer,” JA 65 (capitalization altered), and the language in its precertification letter 18—which was addressed to D.W. 18 The same day Aetna allegedly confirmed to the Center that it had approved D.W.’s surgery and would make payment at the “highest in[-]network level,” Aetna also sent the Center a copy of a precertification letter, addressed to its insured, D.W., identifying fourteen services that had been approved. JA 59. The letter stated, among other things, that “[y]our plan does not have out-of-network benefits”; that coverage for the fourteen services was “approved, subject to the requirements of this letter”; and that approval was “at an in-network benefit level,” subject to “any applicable dollar limits.” Defs.’ Mot. to Dismiss Ex. 2, ECF No. 12-2, at 1, 7–8. It also advised that reimbursement would “be based on standard coding and bundling logic and any mutually agreed upon contracted or negotiated rates, subject to any and all copays or coinsurance requirements”; that D.W. would “be responsible . . . for innetwork cost-sharing requirements”; and that D.W. “should refer to the plan document to determine exclusions and limitations under the plan.” Id. at 1, 7. Though the precertification letter is extraneous to the pleadings, we consider it because it is integral to the pleadings. See Angstadt v. Midd-W. Sch. Dist., 377 F.3d 338, 342 (3d Cir. 2004). 24 but also copied to the Center—stating that “the member’s eligibility for coverage under the plan [has been verified]” and that reimbursement would be based on “standard coding and bundling logic and any mutually agreed upon contracted or negotiated rates,” Defs.’ Mot. to Dismiss Ex. 2, ECF No. 12-2, at 1, 7. From this evidence, Aetna argues we may plausibly infer that the agreement was for the benefits and not merely the rate of payment set forth in the plan. Be that as it may, it does not render the Center’s inferences implausible: The notes go on to document other statements supporting the Center’s position, and Aetna concedes the precertification letter was drafted not for the benefit of the Center, but for the benefit of its insured, D.W. In short, even assuming a different inference is also plausible, at the motion to dismiss stage, we must view the allegations in the light most favorable to the Center and draw all reasonable inferences in the Center’s favor. When we do so, the claims as pleaded are not for benefits due under the plans. Nor are the claims otherwise impermissibly predicated on the plan or plan administration. Because, as alleged, it is Aetna’s oral offers or oral promises (as the case may be) rather than the terms of the plan that define the scope of Aetna’s duty, the plans are not “critical factor[s] in establishing liability.” 19 See Ingersoll-Rand, 498 U.S. at 139–40. 19 To establish its breach of contract claims, the Center may put forth evidence of oral offers and acceptances giving rise to non-plan-based duties, see Williams v. Vito, 838 A.2d 556, 560 (N.J. Super. Ct. Law. Div. 2003) (“[A]bsent a statute to the contrary, an oral offer and acceptance constitutes a binding agreement . . . .”), and evidence of its performance as valuable consideration for that binding agreement, see Martindale v. 25