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FMS Nephrology Partners North Central Indiana Dialysis Centers, LLC v. Meritain Health, Inc.

Court of Appeals of Indiana

March 4, 2019

FMS Nephrology Partners North Central Indiana Dialysis Centers, LLC, Appellant-Plaintiff,
v.
Meritain Health, Inc., Beacon Health System, Inc., Beacon Health System Group Benefit Plan, Beacon Health System Group Benefit Plan - Union Plan, University of Notre Dame Du Lac, University of Notre Dame CHA HMO Plan (Medical), University of Notre Dame Select HMO Plan (Medical), and University of Notre Dame PPO Plan (Medical), Appellees-Defendants.

          Appeal from the St. Joseph Superior Court Trial Court Cause No. 71D07-1605-PL-194 The Honorable Steven L. Hostetler, Judge.

          Attorneys for Appellant Stephanie L. Nemeth Anderson Agostino & Keller, P.C. South Bend, Indiana Caroline Turner English Brian D. Schneider Emily Baver Slavin Arent Fox LLP Washington, DC

          Attorneys for Appellees Beacon Health System, Inc., Beacon Health System Group Plan, and Beacon Health System Group Plan - Union Plan Joseph L. Amaral R. William Jonas Hammerschmidt, Amaral & Jonas South Bend, Indiana Richard B. Urda, Jr. Urda Professional Corporation South Bend, Indiana

          Attorneys for Appellees University of Notre Dame du Lac, University of Notre Dame CHA HMO Plan (Medical), University of Notre Dame Select HMO Plan (Medical), and University of Notre Dame PPO Plan (Medical) Brian E. Casey Kelly J. Hartzler Alice J. Springer Barnes & Thornburg LLP South Bend, Indiana

          Bradford, Judge.

         Case Summary

         [¶1] FMS Nephrology Partners North Central Indiana Dialysis Centers, LLC ("FMS") provides dialysis to patients suffering from end-stage renal disease. FMS filed suit against Meritain Health, Inc.; Beacon Health System, Inc.; Beacon Health System Group Benefit Plan; Beacon Health System Group Benefit Plan-Union Plan (collectively, "the Beacon Appellees"); University of Notre Dame du Lac; University of Notre Dame CHA HMO Plan (Medical); University of Notre Dame Select HMO Plan (Medical); and University of Notre Dame PPO Plan (Medical) (collectively, "the Notre Dame Appellees") (collectively all together, "the Appellees") claiming that Appellees failed to provide proper payment for services rendered by FMS. The Beacon and Notre Dame Appellees sought summary judgment, arguing that FMS's claims against them were preempted by the Employee Retirement Income Security Act ("ERISA"). The trial court agreed and granted summary judgment in favor of the Beacon and Notre Dame Appellees. FMS challenges the award of summary judgment on appeal. Because the record demonstrates that resolution of each of the claims at issue requires interpretation of the provisions of an ERISA-governed health plan, we are firmly convinced that FMS's claims against the Beacon and Notre Dame Appellees are preempted by ERISA. We therefore affirm.

         Facts and Procedural History[1]

         I. The Parties

         [¶2] FMS provides dialysis for patients suffering from end-stage renal disease. The Beacon Health System Group Benefit Plan and the Beacon Health System Group Benefit Plan-Union Plan (collectively, "the Beacon Plans") are welfare plans offering healthcare and medical benefits to eligible employees of Beacon Health System, Inc., and their dependents. Beacon Health System is the sponsor, plan administrator, and named fiduciary of the Beacon Plans. The Notre Dame CHA HMO Plan (Medical), University of Notre Dame Select HMO Plan (Medical), and University of Notre Dame PPO Plan (Medical) (collectively, the Notre Dame Plans") are health plans offering medical benefits to eligible employees of the University of Notre Dame du Lac and their dependents. The University of Notre Dame du Lac is the sponsor, plan administrator, and named fiduciary of the Notre Dame Plans. Meritain serves as the third-party claims administrator for the Beacon and Notre Dame Plans. As the third-party claims administrator, Meritain is responsible for overseeing network contracts and adjudicating claims and appeals for reimbursement from the Beacon and Notre Dame Plans in accordance with network and other agreements.

         II. Services Rendered to Patients/Disputes Relating to Payment

         A. The Beacon Appellees

         [¶3] The Beacon Plans provided participants and their beneficiaries with certain medical benefits as detailed by the Plans. The Beacon Plans also set forth the exclusive procedure for a participant or beneficiary to appeal the denial of a claim. The claims procedures, as adopted, complied with the requirements of ERISA and the regulations promulgated by the United States Department of Labor. Each procedure required an appeal be filed by a participant or beneficiary or the claimant's legal representative within 180 days after notice of the initial denial of the claim.

         [¶4] In its lawsuit, FMS alleged insufficient payment relating to two Beacon patients, who were participants in the Beacon Plans. The first received dialysis services from FMS from July of 2012 through March of 2015. The second received dialysis services from FMS from June of 2013 through May of 2015. Some, but not all, of the charges relating to the services provided by FMS were paid by the Beacon Plans after approval by Meritain.

         B. The Notre Dame Appellees

         [¶5] The Notre Dame Plans provided participants and beneficiaries with certain medical benefits as detailed by the Plans and defined the medical expenses eligible for coverage. The Notre Dame Plans also set forth the procedure for filing an appeal following denial of a claim. The claims procedures, as adopted, complied with the requirements of ERISA and the regulations promulgated by the United States Department of Labor.

         [¶6] In its lawsuit, FMS alleged insufficient payment relating to five Notre Dame patients, who were participants in the Notre Dame Plans and received dialysis services from FMS for the following periods:

Patient 1-March of 2011 through November of 2013,
Patient 2-August of 2013 through November of 2014,
Patient 3-December of 2013 through January of 2015,
Patient 4-January of 2013 through June of 2013, and
Patient 5-April of 2012 through March of 2014.

         Some, but not all, of the charges for services provided by FMS to the patients were paid by the Notre Dame Plans after approval by Meritain. For instance, some of the charges specifically relating to one of the patients were not paid after the services at issue were found to not qualify as "covered ...


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