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Home > Blog > Medical Providers’ Claims Challenging Rate of Reimbursement from Insurance Company are Not Preempted by ERISA

Medical Providers’ Claims Challenging Rate of Reimbursement from Insurance Company are Not Preempted by ERISA

In an unpublished decision, Emergency Group of Arizona Professional Corporation, et al., v. United Healthcare, Inc., No. 20-15684, __F.App’x__, 2021 WL 816071 (9th Cir. Mar. 3, 2021), the Ninth Circuit reversed the district court’s decision finding that out-of-network emergency medical providers’ claims against United Healthcare, Inc. are preempted by ERISA.

Plaintiff-Appellants brought state-law claims against United Healthcare, Inc. challenging United’s rate of reimbursement for services provided to its insureds. The court analyzed the two-prong test set forth by the Supreme Court in Aetna Health Inc. v. Davila on whether a claim is preempted by ERISA. The first prong asks whether the plaintiff could have brought the claim under ERISA and the second prong asks if there is another independent legal duty that is implicated by the defendant’s actions.

The court found the second prong to be dispositive. “The Medical Groups assert legal duties arising under an implied-in-fact contract based on a course of dealing between the parties,” which the court found would exist absent an ERISA plan. Because the claims are based on independent legal duties, they are not completely preempted by ERISA. The court remanded the case to the district court with instructions to remand the case back to state court.

The three-judge panel included William Fletcher, Eric Miller, and Danielle Hunsaker.

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