Court Opinion

ID: 3198234
Source: CourtListenerOpinion
Date Created: 2016-04-27 14:00:58.63563+00
Date Added: 2024-06-11T07:39:12.192662
License: Public Domain

Case: 15-12858   Date Filed: 04/27/2016   Page: 1 of 10

                                                      [DO NOT PUBLISH]

            IN THE UNITED STATES COURT OF APPEALS

                     FOR THE ELEVENTH CIRCUIT
                       ________________________

                             No. 15-12858
                         Non-Argument Calendar
                       ________________________

                     D.C. Docket No. 1:15-cv-00147-AT

W. A. GRIFFIN, MD,

                                                        Plaintiff - Appellant,

                                  versus

SUNTRUST BANK, INC.,

                                                      Defendant - Appellee.

                       ________________________

                Appeal from the United States District Court
                   for the Northern District of Georgia
                      ________________________

                              (April 27, 2016)
                Case: 15-12858       Date Filed: 04/27/2016        Page: 2 of 10

Before WILLIAM PRYOR, JILL PRYOR and FAY, Circuit Judges.

PER CURIAM:

       Proceeding pro se, Dr. W.A. Griffin appeals the district court’s grant of

judgment on the pleadings under the Employee Retirement Income Security Act of

1974 (“ERISA”), 29 U.S.C. § 1132(a). After careful consideration, we affirm. 1

                                                I.

       Dr. Griffin, who operates a dermatology practice in Atlanta, Georgia, treated

a patient insured under a SunTrust Bank, Inc. (“SunTrust”) sponsored group health

benefit plan (the “Plan”).2 Dr. Griffin is an out-of-network provider under the

Plan. She requires her patients to assign their insurance benefits to her.

       The Plan is an employee welfare benefit plan under ERISA that provides

participants with medical-related benefits. SunTrust is the plan sponsor, and Blue

       1
          Dr. Griffin’s motion for expedited consideration, a three-judge panel, and a published
opinion is also pending before us. We deny her motion. Her request for a three-judge panel is
moot because our rules provide that she is entitled to a three-judge panel. See 11th Cir. R. 34-2,
34-3(e). As regards her request for a published opinion, our rules provide that “[a]n opinion
shall be unpublished unless a majority of the panel decides to publish it.” 11th Cir. R. 36-2. In
this case, the panel decided not to publish. While our rules permit a party to file a motion
requesting that a previously unpublished order be published, they provide that the motion shall
be granted only if the panel unanimously agrees to publish. 11th Cir. R. 36-3. Construing Dr.
Griffin’s motion as requesting publication under Rule 36-3, the request is premature, and we
deny it. Further, we deny her request for expedited consideration as moot.
       2
          On a review of a motion for judgment on the pleadings, we accept the well-pled
allegations in the complaint as true and view them in the light most favorable to Dr. Griffin. See
Cannon v. City of W. Palm Beach, 250 F.3d 1299, 1301 (11th Cir. 2001). We may consider the
Employee Benefit Plan and Administrative Services Agreement, which SunTrust attached to its
answer, in reviewing the motion for judgment on the pleadings because the documents are
central to Dr. Griffin’s complaint and their authenticity is undisputed. Horsley v. Feldt, 304 F.3d
1125, 1134-35 (11th Cir. 2002).
                                                 2
                 Case: 15-12858         Date Filed: 04/27/2016        Page: 3 of 10

Cross Blue Shield of Georgia (“BCBSGA”) is the claims administrator. The

Employee Benefit Plan document sets forth the terms and conditions of the

agreement between SunTrust and its employee participants. The Employee Benefit

Plan contains an anti-alienation clause that generally prohibits a plan participant or

beneficiary from assigning “all or any portion of any benefit, payment or

distribution under this Plan except to the extent expressly provided in this Plan or a

Benefit Option.” Employee Benefit Plan § 14.1 (Doc. 5-1).3 But there is an

important limitation: a participant or beneficiary may assign benefits to a

healthcare provider.

      Dr. Griffin’s patient was insured under the Plan. Pursuant to the patient’s

assignment, Dr. Griffin submitted a claim to BCBSGA, which was denied. Dr.

Griffin then filed with BCBSGA a level-one administrative appeal of the claim.

With her appeal, she requested at least six broad categories of documents

connected to the Plan. Dr. Griffin later filed a level-two administrative appeal and

requested a copy of the summary plan description. BCBSGA never responded to

her appeals or sent the requested plan documents. Instead, BCBSGA determined

that it had incorrectly denied the original claim and paid Dr. Griffin $909.37 on the

claim. Dr. Griffin contends that BCBSGA still underpaid the claim by

approximately $1,000. Dr. Griffin then demanded BCBSGA submit the claim to

      3
          Citations to “Doc.” refer to docket entries in the district court record in this case.
                                                   3
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an independent review organization for external review. BCBSGA never

responded to this request.

      Dr. Griffin sued SunTrust in federal court, bringing causes of action under

ERISA for (1) unpaid benefits, (2) breach of fiduciary duty, (3) failure to provide

plan documents, and (4) breach of contract based on SunTrust’s breach of its

fiduciary duty. She demanded $999.29 in unpaid benefits, $65,560 in penalties,

and declaratory relief. SunTrust filed an answer and then a motion for judgment

on the pleadings. While the motion for judgment on the pleadings was pending,

Dr. Griffin sought leave to amend her complaint to add a cause of action based

upon co-fiduciary liability under ERISA. The district court granted the motion for

judgment on the pleadings and denied the motion to amend, concluding that (1) Dr.

Griffin failed to state a claim against SunTrust for unpaid benefits under the Plan

because Dr. Griffin made no allegation that SunTrust actually exercised any

discretionary authority with respect to the claim and (2) Dr. Griffin lacked

statutory standing to pursue the other causes of action because the assignment from

her patient transferred only the right to bring a cause of action for unpaid benefits.

The district court then entered a judgment dismissing the case. This appeal

followed.

                                          II.

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              Case: 15-12858     Date Filed: 04/27/2016   Page: 5 of 10

       We review de novo an order granting judgment on the pleadings. Cannon v.

City of W. Palm Beach, 250 F.3d 1299, 1301 (11th Cir. 2011). “Judgment on the

pleadings is appropriate where there are no material facts in dispute and the

moving party is entitled to judgment as a matter of law.” Id. In reviewing an order

granting judgment on the pleadings, “we accept as true all material facts alleged in

the non-moving party’s pleadings, and we view those facts in the light most

favorable to the non-moving party.” Perez v. Wells Fargo N.A., 774 F.3d 1329,

1335 (11th Cir. 2014). In addition, “[p]ro se pleadings are held to a less stringent

standard than pleadings drafted by attorneys and are liberally construed.” Bingham

v. Thomas, 654 F.3d 1171, 1175 (11th Cir. 2011) (internal quotation marks

omitted).

                                         III.

      We begin by considering the district court’s determination that Dr. Griffin

failed to state a claim against SunTrust for unpaid benefits. ERISA permits a plan

participant or beneficiary to bring a civil action “to recover benefits due to him

under the terms of his plan.” 29 U.S.C. § 1132(a)(1)(B). Dr. Griffin “acquire[d]

derivative standing to sue under ERISA by obtaining a written assignment” from

her patient of the right to payment of medical benefits. Conn. State Dental Ass’n v.

Anthem Health Plans, Inc., 591 F.3d 1337, 1347 (11th Cir. 2009). The Plan

permits assignment of benefits to healthcare providers.

                                          5
              Case: 15-12858    Date Filed: 04/27/2016   Page: 6 of 10

      Although § 1132(a)(1)(B) specifies that only plan participants and

beneficiaries may bring a cause of action for unpaid benefits, the statute does not

address who is a proper defendant to this cause of action. See 29 U.S.C.

§ 1132(a)(1)(B); Harris Trust & Sav. Bank v. Salomon Smith Barney Inc., 530 U.S.
238, 246 (2000) (explaining that similar provision in § 1132(a)(3) “makes no

mention at all of which parties may be proper defendants”). When considering this

question, we must keep in mind that “ERISA’s ‘comprehensive and reticulated’

scheme warrants a cautious approach to inferring remedies not expressly

authorized by the text.” Harris, 530 U.S. at 247 (quoting Mass. Mut. Life Ins. Co.

v. Russell, 473 U.S. 134, 146 (1985)).

      We have previously recognized that “[t]he proper party defendant in an

action concerning ERISA benefits is the party that controls the administration of

the plan.” Garren v. John Hancock Mut. Life Ins. Co., 114 F.3d 186, 187 (11th

Cir. 1997). We reached this conclusion because a court order requiring the

payment of benefits under ERISA “must issue against a party capable of providing

the relief requested.” Hunt v. Hawthorne Assocs., Inc., 119 F.3d 888, 908 (11th

Cir. 1997). We explained that proof that an entity controls the administration of

the plan “may come from the plan document, but can also come from the factual

circumstances surrounding the administration of the plan, even if these factual

                                          6
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circumstances contradict the designation in the plan document.” Hamilton v.

Allen-Bradley Co., Inc., 244 F.3d 819, 824 (11th Cir. 2001).

      The plan documents show that SunTrust retained authority to direct

BCBSGA to pay any claim, even after BCBSGA denied the claim. Under the

Employee Benefit Plan document, SunTrust was generally “responsible for the

control, management and administration of [the] Plan,” although it was permitted

to delegate its responsibilities. Employee Benefit Plan at § 10.1 (Doc. 5-1). The

Administrative Services Agreement defined the extent to which SunTrust

delegated to BCBSGA its authority to determine claims. SunTrust transferred to

BCBSGA the responsibility to “[p]rocess claims,” including determining the

amount owed, and to decide “appeals of any adverse benefit determinations under

the Plan.” Administrative Services Agreement § 2(b), (c) (Doc. 5-2). SunTrust

permitted BCBSGA to use its own policies and procedures in making these

determinations. SunTrust gave BCBSGA “full discretion to determine eligibility

for benefits under the Plan and to interpret the terms of the Plan.” Id. § 2(c).

Despite this broad delegation of authority, however, SunTrust explicitly reserved

the right to demand that BCBSGA pay any claim: “[SunTrust] may request

                                           7
                Case: 15-12858        Date Filed: 04/27/2016       Page: 8 of 10

[BCBSGA], on exception basis, to process and pay Claims that were denied by

[BCBSGA].” Id. § 3(j). 4

       Although SunTrust retained authority to direct BCBSGA to pay claims on an

exception basis, we hold that SunTrust may not be held liable for unpaid benefits

under ERISA on the facts of this case. Dr. Griffin has not alleged that she

appealed BCBSGA’s denial of her claim to SunTrust or that SunTrust sua sponte

reviewed her claim. Indeed, she has not alleged that SunTrust took any action

whatsoever with respect to her claim. We have previously described a cause of

action under § 1132(a)(1)(B) for unpaid benefits as “akin to [a] common law

breach of contract cause[] of action.” Jones v. Am. Gen. Life & Acc. Ins. Co., 370
F.3d 1065, 1069 (11th Cir. 2004). Because Dr. Griffin failed to allege that

SunTrust took any action with respect to her claim that would be analogous to a

breach, SunTrust cannot be held liable for unpaid benefits.

       This conclusion is consistent with the plain language of ERISA, which

specifies that “[a]ny money judgment under this subchapter against an employee

benefit plan shall be enforceable only against the plan as an entity and shall not be

enforceable against any other person unless liability against such person is

       4
           SunTrust argues that it lacked control over claims determinations under § 3(j) because it
could only request, not dictate, that BCBSGA pay a previously denied claim. We respectfully
disagree. Subsection 3(j) makes clear that when SunTrust requests BCBSGA pay a claim,
BCBSGA’s subsequent actions are taken “at direction of, [and] in accordance with, instructions”
from SunTrust. Administrative Services Agreement §3(j) (Doc. 5-2). Given the characterization
of SunTrust’s actions as “directions” and “instructions,” we disagree with SunTrust’s assertion
that it lacked authority to determine claims under the Plan.
                                                 8
              Case: 15-12858      Date Filed: 04/27/2016   Page: 9 of 10

established in his individual capacity under this subchapter.” 29 U.S.C.

§ 1132(d)(2). We read the “unless” cause in § 1132(d)(2) to indicate that

SunTrust, an entity distinct from the Plan, can be liable for money damages on a

cause of action for unpaid benefits only when its individual liability is established.

Because we cannot say that Dr. Griffin’s allegations are sufficient to establish

SunTrust’s individual liability, we conclude that the district court correctly

dismissed this cause of action.

                                          B.

      We now turn to whether the district court properly dismissed Dr. Griffin’s

remaining causes of action for lack of standing. In Count 2, Dr. Griffin sued for

breach of fiduciary duty, but ERISA limits the right to sue for breach of fiduciary

duty to plan participants, plan beneficiaries, plan fiduciaries, and the Secretary of

Labor. See 29 U.S.C. § 1132(a)(2). In Count 3, Dr. Griffin sued seeking statutory

penalties for failure to comply with a request for information under ERISA, but

ERISA permits only a participant or beneficiary to sue for statutory penalties. See

id. § 1132(a)(1)(A), (c). In Count 4, Dr. Griffin sued for breach of contract and

sought equitable relief, but under ERISA only plan participants, plan beneficiaries,

and plan fiduciaries may bring a civil action to obtain equitable relief to redress a

practice that violates ERISA or the terms of a plan. See id. § 1132(a)(3). Dr.

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               Case: 15-12858       Date Filed: 04/27/2016       Page: 10 of 10

Griffin asserts that she acquired derivative standing to bring these causes of action

through her patient’s assignment. We disagree.

       An assignee may obtain derivative standing through a written assignment

from a plan participant or plan beneficiary. See Gables Ins. Recovery v. Blue

Cross & Blue Shield of Fla., Inc., 813 F.3d 1333, 1339 (11th Cir. 2015). Dr.

Griffin alleges only that her patient agreed to a “legal assignment of benefits.”

Compl. at ¶ 22 (Doc. 1). Nothing in an assignment of benefits transfers the

patient’s right to bring a cause of action for breach of fiduciary duty, to seek

statutory penalties for failure to provide plan documents, or to seek equitable relief

to redress a practice that violates ERISA or the terms of the Plan. Because the

patient never transferred these rights to Dr. Griffin, the district court correctly

determined that Dr. Griffin lacked standing to assert the causes of action set forth

in Counts 2, 3, and 4.

                                               IV.

       We conclude that the district court properly granted SunTrust’s motion for

judgment on the pleadings. Accordingly, we affirm. 5

       AFFIRMED.

       5
         Dr. Griffin also argues that the district court erred in denying her motion to amend her
complaint to add an additional cause of action under ERISA. We review the district court’s
denial of a motion to amend a complaint for abuse of discretion, but we review de novo whether
the proposed amendment to the complaint would be futile. See Harris v. Ivax Corp., 182 F.3d
799, 802-03 (11th Cir. 1999). Because Dr. Griffin lacked derivative standing to bring a co-
fiduciary liability cause of action under the assignment, the proposed amendment would be
futile. Thus, the district court properly denied the motion to amend.
                                               10