Sixth Circuit Rejects Hospitals’ Attempt to Expand Insurers’ Payment Obligations for Emergency Care

In AMISUB (SFH), Inc. v. Cigna Health & Life Ins. Co., No. 23-5714, —F.4th—-, 2025 WL 1806073 (6th Cir. July 1, 2025), the Sixth Circuit affirmed the dismissal of a lawsuit brought by two Tennessee hospitals against Cigna Health and Life Insurance Company. The court decisively rejected the hospitals’ claim that Cigna was legally obligated to pay the “full value” of emergency services provided on an out-of-network basis—even absent any contract between the parties. The decision reinforces the boundaries of federal and state healthcare mandates and declines to impose broader quasi-contractual duties on insurers in the absence of statutory language or a preexisting contractual relationship.

The plaintiffs—Saint Francis Hospital and Saint Francis Hospital–Bartlett—alleged that Cigna systematically underpaid them for emergency care rendered to Cigna members after their contractual agreement expired in 2019. Operating without a network contract, the hospitals claimed that Cigna nonetheless owed them payment beyond the terms of its health plans, based on equitable doctrines of quantum meruit and unjust enrichment under Tennessee common law. Their theory relied in part on the Emergency Medical Treatment and Labor Act (EMTALA) and the Affordable Care Act (ACA), which require hospitals to provide emergency care and insurers to provide emergency coverage. The hospitals argued that these laws create a de facto relationship between providers and insurers, compelling insurers like Cigna to pay the “reasonable value” of services rendered, regardless of plan terms.

The district court granted Cigna’s motion to dismiss on three grounds: “(1) the complaint violated Rule 8’s pleading standards by not pleading information specific to each instance of underpayment, (2) Tennessee common law provides no basis for such a suit, and (3) ERISA preempts the ability of a state to allow such a suit.”

On appeal, the Sixth Circuit noted that on de novo review of the district court’s dismissal, it can affirm on any ground supported by the record. The court did not address whether ERISA preemption applies or the district court’s holding that the Hospitals should have included claim-specific information in the complaint. The court held that Cigna had no independent legal duty to pay more than what its member contracts required. The court clarified that while the ACA mandates “coverage” for emergency care, this does not equate to full reimbursement of a provider’s billed charges. Rather, federal regulations define minimum payment standards using the so-called “greatest-of-three” rule, which calculates payment based on the highest of three benchmark rates. Crucially, the regulation recognizes that patients—not insurers—may remain responsible for the balance between provider charges and insurer reimbursement.

The court also distinguished the plaintiffs’ case from other precedent involving Medicaid and Medicare providers, who often have contractual or statutory obligations to cover full costs. In contrast, Cigna had no such duty under Tennessee law, and the state’s statute mirrored the ACA in requiring only “coverage,” not full payment.

The hospitals’ fallback position—that Tennessee common law principles of unjust enrichment or quantum meruit required Cigna to pay more—was also rejected. The court emphasized that no Tennessee case recognizes an equitable obligation on insurers to pay beyond the terms of their member contracts in this context. While the hospitals pointed to River Park Hospital, Inc. v. BlueCross BlueShield of Tennessee, Inc., 173 S.W.3d 43 (Tenn. Ct. App. 2002), that decision involved a Medicaid contractor bound by state agreement to cover full costs—a key distinction not present here.

Additionally, the court declined to be persuaded by a Restatement illustration or out-of-state cases that similarly turned on facts not applicable to Cigna. In the absence of a clear legal duty, the court found that the hospitals’ claims amounted to a policy argument better addressed by legislation, such as the No Surprises Act (NSA), which was enacted after the events in question to address precisely this issue.

“In sum, aside from pointing to opinions from one district court and one state court that did not consider the necessity of an insurer having a duty to fully cover emergency care, the Hospitals cite no case supporting their cause of action absent a statute or regulation imposing this duty on insurers.”