Dr. Komarnisky may prefer that Cigna pay for his services, rather than his patients, but that does not mean Cigna legally injures him by declining to pay out benefits. The law is clear that if a determination to not pay is unreasonable, only a plan participant, beneficiary, fiduciary, or valid assignee is the injured party and may bring an ERISA claim. See Id. at 1289. Because Dr. Komarnisky has not shown that he is any of the above, he has not shown Cigna legally injured him. Even though he is a health-care provider, Dr. Komarnisky is not automatically entitled to bring an ERISA claim.
Komarnisky v. CIGNA Healthcare of Arizona (D. Ariz. 2021)
This recent opinion demonstrates once again the recurring problem of anti-assignment clauses. Since only a fiduciary, participant or beneficiary may assert an ERISA claim for benefits, a health care provider must obtain a valid assignment to pursue a claim against an insurer or health plan.
“Health care providers may pursue an ERISA claim provided that a patient has assigned the provider its benefits claim. Spinedex, 770 F.3d at 1289. However, if an ERISA plan contains an anti-assignment clause, then the claim may not be assigned. Id. at 1296 (“Anti-assignment clauses in ERISA plans are valid and enforceable.”). Cigna argues that Dr. Komarnisky lacks standing to bring an ERISA claim because he is not a plan participant, a beneficiary, or fiduciary.”
And the problem is exacerbated by ERISA preemption of any health plan provider claims other than § 502(a)(1)(B) claims. As the district court stated:
“If a state-law cause of action falls within the scope of § 502(a)(1)(B), “those causes of action are completely preempted, and the only possible cause of action is under § 502(a)(1)(B).” Marin Gen. Hosp. v. Modesto & Empire Traction Co., 581 F.3d 941, 946 (9th Cir. 2009); see also Aetna Health Inc. v. Davila, 542 U.S. 200, 209 (2004) (“[A]any state-law cause of action that duplicates, supplements, or supplants the ERISA civil enforcement remedy conflicts with the clear congressional intent to make the ERISA remedy exclusive and is therefore pre-empted.”). This is to say that once an ERISA claim is made, a plaintiff may not bring similar state-law claims seeking benefits for an ERISA plan. Id.”
Note: For a more in-depth look at the policy implications of anti-assignment clauses, see Jordan Davis, Seeking a Second Opinion: A Call for Congressional Evaluation of Anti-assignment Provisions in Employee Health Plans, 89 Fordham L. Rev. 2265 (2021).
Circuit Courts of Appeal – For 11th Circuit, see Griffin v. Coca-Cola Refreshments USA, No. 18-10417, 2021 WL 712419 (11th Cir. Feb. 24, 2021), well summarized at Your ERISA Watch here; 9th Circuit, see Ninth Circuit Rules in Favor of Medical Provider in Dispute with Insurer Regarding Anti-Assignment Provisions; 3rd Circuit, see Health Plans’ Anti-Assignment Clauses Upheld by Third Circuit.
Article III Standing – The issue falls more broadly under the heading of standing to sue:
“Article III of the Constitution establishes that federal courts may only hear cases or controversies. Lujan v. Defs. of Wildlife, 504 U.S. 555, 559 (1992). To satisfy this constitutional requirement, a plaintiff must have suffered a concrete and particularized injury that is both fairly traceable to the defendant’s conduct and redressable by a favorable decision. Id. at 560-61.“