LibGuides: Health Care Claims Disputes: Additional Florida Cases

Elements of Third-Party Standing

The following four elements are required: "(1) existence of a contract; (2) the clear or manifest intent of the contracting parties that the contract primarily and directly benefit the third party; (3) breach of the contract by a contracting party; and (4) damages to the third party resulting from the breach."
Found. Health v. Westside EKG Assocs., 944 So. 2d 188, 194-195 (Fla. 2006).

Network Membership NOT Required

Florida Administrative Code Subsection 641.3154(1) provides that an HMO is liable for services rendered by a provider to an HMO member whether there is a contract between the HMO and the provider. Health Options, Inc. v. Palmetto Pathology Servs., P.A., 983 So. 2d 608, 614 (Fla. Dist. Ct. App. 3d Dist. 2008).

Supplemental Jurisdiction over Related Claims

In this case, health care provider . . . as assignee of 21 patients, seeks to recover funds from insurer Blue Crossand Blue Shield of Florida, Inc. . . . owed for medical services provided to the patients, citing the Employment Retirement Income Security Act of 1974.

Kindred Hosp. E. L.L.C. v. Blue Cross & Blue Shield of Florida, Inc., 3:05CV995J32TEM, 2007 WL 601749 (M.D. Fla. Feb. 16, 2007)

Excellent Layout of Elements of Coverage Dispute

Equitable Estoppel May Be Used to Enforce Verficiation of Coverage
The elements of equitable estoppel, as defined by federal common law, are: (1) the party to be estopped misrepresented material facts; (2) the party to be estopped was aware of the true facts; (3) the party to be estopped intended that the misrepresentation be acted on or had reason to believe the party asserting the estoppel would rely on it; (4) the party asserting the estoppel did not know, nor should have known, the true facts; and (5) the party asserting the estoppel detrimentally relied on the misrepresentation.

Albright v. Union Bankers Ins. Co., 105 F. Supp. 2d 1330, 1334-35 (S.D. Fla. 2000)

Plaintiff filed the Complaint in this case in state court alleging: (1) fraudulent misrepresentation, (2) negligent misrepresentation, (3) false information negligently supplied for guidance of others, and (4) promissory estoppel.

Kindred Hospitals E., LLC v. Fox-Everett, Inc., 3:12-CV-307-J-37MCR, 2012 WL 5467516 (M.D. Fla. Oct. 4, 2012) report and recommendation adopted, 3:12-CV-307-J-99MMH, 2012 WL 5467553 (M.D. Fla. Nov. 9, 2012)

Fraudulent Misrepresentation

To state a claim for fraudulent misrepresentation, a plaintiff must plead four elements: “ ‘(1) a false statement concerning a material fact; (2) the representor's knowledge that the representation is false; (3) an intention that the representation induce another to act on it; and (4) consequent injury by the party acting in reliance on the representation.

Negligent Misrepresentation

In order to state a claim for negligent misrepresentation, a plaintiff is required to show: (1) misrepresentation of a material fact; (2) that Defendant knew of the misrepresentation, made the misrepresentation without knowledge as to its truth or falsity, or made the misrepresentation under circumstances in which it ought to have known of its falsity; (3) Defendant intended the representation would induce Plaintiff to act on it; and (4) injury to Plaintiff because it acted in good justifiable reliance on the misrepresentation.

False Information Negligently Supplied for the Guidance of Others

The Florida Supreme Court expressly recognized a cause of action for “Information Negligently Supplied for the Guidance of Others” in Gilchrist Timber Co. v. ITT Rayonier, Inc., 696 So.2d 334, 337–39 (Fla.1997). Further, a claim for information negligently supplied for the guidance of others requires the defendant to have supplied the false information during “the course of his business, profession or employment, or in any other transaction in which he has a pecuniary interest.”

Promissory Estoppel

To state a claim for promissory estoppel, a plaintiff must allege the following elements: (1) [a] promise which the promisor should reasonably expect to induce action or forbearance on the part of the promisee or a third person, (2) the promise “does induce such action or forbearance,” and (3) “injustice can be avoided only by enforcement of the promise.

Assignment by Insured is Adequate to Attain Standing
Parkway's allegation of assignment in Count VI of its complaint is sufficient to state a cause of action against Allstate as required by Fla.R.Civ.P. 1.110.

Parkway Gen. Hosp., Inc. v. Allstate Ins. Co., 393 So. 2d 1171, 1173 (Fla. Dist. Ct. App. 1981)
Substantially Complete Claim = Timely Notice
Florida section 627.736, the insurer is put on notice of a covered claim by the submission of a substantially complete claim form.

GEICO Gen. Ins. Co. v. Tarpon Total Health Care, 86 So. 3d 585, 588 (Fla. Dist. Ct. App. 2d Dist. 2012)
High Cost Outlier Payments are Permitted
Under Champus, the contractor is permitted to pay network providers beyond the Government's allowed amounts.

, Baptist Physician Hosp. Org., Inc. v. Humana Military Healthcare Servs., 368 F.3d 894, 901 (6th Cir. Tenn. 2004)
Fiduciary and Claims Administration = Conflict of Interest?
The "modified Williams test":
1. De novo determine if claim administrator's benefits-denial decision is "wrong". If not, end inquiry and affirm decision.
2. Administrator's decision is "de novo wrong," and administrator was not vested with discretion in reviewing claims, end judicial inquiry and reverse the decision.
3. Decision is "de novo wrong" but administrator vested with discretion in reviewing claims, did "reasonable" grounds support it? (hence, review his decision under deferential arbitrary and capricious standard).
4. If no reasonable grounds exist, end inquiry and reverse decision; if reasonable grounds exist, determine if he operated under a conflict of interest.
5. No conflict, end inquiry and affirm decision.
6. If there is a conflict, the conflict becomes a factor to take into account when determining whether an administrator's decision was arbitrary and capricious.
Blankenship v. Metropolitan Life Ins. Co., 644 F.3d 1350, 1355 (11th Cir. 201

Things of Note

Cost to Charge Ratio Manipulation Boca Raton Cmty. Hosp., Inc. v. Tenet Healthcare Corp., 502 F. Supp. 2d 1237 (S.D. Fla. 2007)

Anti-Assignment Provisions are enforceable, Vardag v. Motorola, Inc., 264 F. Supp. 2d 1056 (S.D. Fla. 2003)

Providers can attain standing - "This court has allowed healthcare providers to use derivative standing to sue under ERISA, it has only done so when the healthcare provider had obtained a written assignment of claims from a patient who had standing to sue under ERISA as a "beneficiary" or "participant."
Hobbs v. Blue Cross Blue Shield, 276 F.3d 1236, 1241 (11th Cir. Ala. 2001)

Medicare Supplement Policies Entitled to Pay at Medicare Per Diem Rate Post-Exhaust, Vencor, Inc. v. Std. Life & Accident Ins. Co., 317 F.3d 629 (6th Cir. Ky. 2003)

Balance Billing NOT Permitted Even for Non-Participating Providers, Joseph L. Riley Anesthesia Assocs. v. Stein, 27 So. 3d 140 (Fla. Dist. Ct. App. 5th Dist. 2010)

Non-Network Providers of Emergency Services Must Be Paid at Usual and Customary Rates (UCR) - "Section 641.513(5)(b), Florida Statutes (2005) requires HMOs to pay healthcare providers, which have no contract with the HMO, for emergency medical treatment rendered to subscribers of the HMO. , Adventist Health System/Sunbelt, Inc. v. Blue Cross & Blue Shield, 934 So. 2d 602, 603 (Fla. Dist. Ct. App. 5th Dist. 2006)

The Cat Ate My Finger is a Tort Case and thus not preempted by ERISA. "Tort claims based upon the duty of care rather than contract claims based solely upon a denial of benefits do not fall 'within the scope of the civil enforcement provisions of § 502(a),' and thus are not completely preempted." Land v. CIGNA Healthcare , 339 F.3d 1286, 1293-1294 (11th Cir. Fla. 2003).

Elements required for preemption - The Four-Part ButeroTest

The application of the Eleventh Circuit's four-part Butero test confirms that independent state law claims of healthcare providers are not subject to ERISA super-preemption. As explained above, a state law claim is super-preempted if it meets the following four conditions: (1) the plaintiff's complaint involves a relevant ERISA plan; (2) the plaintiff has standing to sue under the ERISA plan; (3) the defendant is an ERISA entity; and (4) the complaint seeks compensatory relief akin to what is available under 29 U.S.C. § 1102(a).

1. Not in dispute

2. Standing - For a state law claim to be completely preempted and re-characterized as a federal claim, the plaintiff must have standing to sue under the relevant ERISA plan

3. Not in dispute

4. Relief Akin to Section 1102(a) - Plaintiffs emphasize that their claims are brought under a Florida statute and are unrelated to terms of any healthplan.

Rocky Mt. Holdings, LLC v. Blue Cross & Blue Shield of Fla., Inc., 2008 U.S. Dist. LEXIS 65732 (M.D. Fla. Aug. 13, 2008)

Winning the Fight But Losing the Battle.

Administrative Exhaustion - Plaintiff has exhausted her remedies by consistently demanding payment for the medical services provided by a non-network provider. Lieberman v. United Healthcare Ins. Co., 2010 U.S. Dist. LEXIS 22199 (S.D. Fla. Mar. 10, 2010).

Until a claimant has exhausted her administrative remedies by going through the agency appeals process, a federal district court has no subject matter jurisdiction over her lawsuit seeking to 'recover on any claim arising out of' the Medicare Act."

Kaye v. Humana Ins. Co., 2009 U.S. Dist. LEXIS 17131 (S.D. Fla. Feb. 23, 2009)