Fifth Circuit Issues Revised Opinion in Angelina Emergency Medicine Associates v. Blue Cross: Clarifying the Path Forward for Out-of-Network ERISA Providers

In August, we wrote about the Fifth Circuit’s decision in Angelina Emergency Medicine Associates, P.A. v. Blue Cross and Blue Shield of Alabama, which revived key ERISA claims by Texas emergency-medicine groups against out-of-state Blue Cross plans. (Read our prior post here.)

Now, following a petition for rehearing, the Fifth Circuit has withdrawn its August opinion and issued a revised decision on October 23, 2025, Angelina Emergency Med. Assocs. PA v. Blue Cross & Blue Shield of Alabama, No. 24-10306, —F.4th—, 2025 WL 2984898 (5th Cir. Oct. 23, 2025). The new opinion keeps the same outcome—largely favorable to the physician groups—but clarifies the legal reasoning and provides a more detailed explanation of how equitable estoppel and assignment principles apply under ERISA.

The case involves 56 Texas emergency-medicine physician groups that treated patients covered by 24 out-of-state Blue Cross Blue Shield plans. The physicians alleged that the plans underpaid for out-of-network emergency services, even though patients had assigned their insurance benefits to the providers.

The district court granted summary judgment to the Blue Cross plans, holding that the physicians lacked standing, that the plans’ anti-assignment clauses barred the claims, and that the groups failed to exhaust administrative remedies before filing suit.

In its August 2025 opinion, the Fifth Circuit reversed much of that decision, holding that factual disputes precluded summary judgment and allowing most of the claims to move forward.

What’s New in the October 2025 Opinion

The court explains that the petition for rehearing en banc was granted, but the panel treated it as a panel rehearing under Fifth Circuit Rule 40. As a result, the prior opinion (150 F.4th 393) was withdrawn and replaced with the new version (2025 WL 2984898).

The Fifth Circuit again affirmed summary judgment only for claims where no written assignments existed, and vacated and remanded as to all other claims, finding factual disputes that require further review.

The most significant clarification concerns the type of estoppel that applies when insurers invoke anti-assignment clauses. The earlier opinion held that the district court used the wrong legal test; the new opinion goes further, explaining that there are two distinct doctrines:

• Hermann Hospital estoppel (from Hermann Hosp. v. MEBA Med. & Benefits Plan, 5th Cir. 1992) is an equitable principle preventing an insurer from waiting years to invoke an anti-assignment clause that a provider could not have known about.
• ERISA estoppel (recognized in Mello v. Sara Lee Corp., 5th Cir. 2005) is a narrower doctrine requiring a material misrepresentation, detrimental reliance, and extraordinary circumstances—and generally applies only to plan participants, not providers.

The revised opinion makes clear that Hermann and ERISA estoppel are not the same, and that the district court erred by conflating them and applying the stricter ERISA-estoppel test.

The court refines its discussion of Dialysis Newco, Inc. v. Community Health Systems Group Health Plan (5th Cir. 2019), noting that estoppel was not raised there because the assignment occurred only days before litigation. This change softens the prior suggestion that Dialysis Newco “rejected” estoppel, making the new opinion more consistent with precedent.

On standing and exhaustion of administrative remedies, the Fifth Circuit reaffirmed that:

• Assignments using broad language like “any practitioner providing care” are ambiguous, so extrinsic evidence is needed to determine their scope.
• Assignments of “all rights” or “all insurance benefits” can include the right to sue, even if not stated explicitly.
• The providers’ use of the BlueCard provider appeals process—the only process available to them—creates factual disputes as to whether administrative remedies were properly exhausted.

The revised opinion tightens citations, reorganizes sections for clarity, and adds procedural details, but the substance and result remain the same.

The Fifth Circuit’s revised opinion confirms its earlier message: out-of-network emergency-medicine providers can rely on patient assignments to pursue ERISA and contract claims, provided they can show ambiguity in assignment language or inequitable conduct by insurers.

The new Angelina Emergency Medicine opinion doesn’t change the outcome—it clarifies and strengthens the reasoning supporting the providers’ right to move forward. The Fifth Circuit continues to open the door for ERISA healthcare providers to challenge underpayments, emphasizing that equity and common sense still have a place in assignment-of-benefits disputes.

For additional background, see our earlier post discussing the original August 2025 decision: Fifth Circuit Revives Emergency Physician Groups’ ERISA Claims Against Out-of-State Blue Cross Plans