Innova Hospital of San Antonio sued multiple insurance companies and third-party plan administrators in Texas State Court as an assignee of the insurance benefits owed to the patients treated at its facility alleging that the defendants either failed to pay or reduced payment substantially. The action was removed under ERISA.
The District Court dismissed the hospital’s claims, but the Fifth Cirucit reversed, noting that “the District Court lacked the benefit of the guidance in Electrostim Medical Services v. Health Care Service Corp., 614 Fed.Appx. 731 (5th Cir. 2015), when it dismissed the Hospital’s ERISA claim for plan benefits and breach-of-contract claim…. Even though Electrostim had not identified the specific subscriber health plans indicating what services were covered (and therefore what services had to be reimbursed under the provider agreement), we concluded that Electrostim’s allegations were sufficiently detailed to permit the reasonable inference that the defendant is liable for the misconduct alleged. Moreover, in Electrostim, we declined to adopt a requirement that plaintiffs must always include specific plan language in complaints alleging improper reimbursement under ERISA….
“Simply put, ERISA plaintiffs should not be held to an excessively burdensome pleading standard that requires them to identify particular plan provisions in ERISA contexts when it may be extremely difficult for them to access such plan provisions.”
Innova Hospital San Antonio v. Blue Cross and Blue Shield, No.14-11300, 2018 WL 2943339 (5th Cir. June 12, 2018).