Angel Jet Services, LLC v. Cleveland Clinic Employee Health Plan Total Care

34 F. Supp. 3d 780, 59 Employee Benefits Cas. (BNA) 1259, 2014 WL 3615798, 2014 U.S. Dist. LEXIS 98784
CourtDistrict Court, N.D. Ohio
DecidedJuly 21, 2014
DocketCase No. 1:12CV298
StatusPublished
Cited by4 cases

This text of 34 F. Supp. 3d 780 (Angel Jet Services, LLC v. Cleveland Clinic Employee Health Plan Total Care) is published on Counsel Stack Legal Research, covering District Court, N.D. Ohio primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

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Angel Jet Services, LLC v. Cleveland Clinic Employee Health Plan Total Care, 34 F. Supp. 3d 780, 59 Employee Benefits Cas. (BNA) 1259, 2014 WL 3615798, 2014 U.S. Dist. LEXIS 98784 (N.D. Ohio 2014).

Opinion

OPINION AND ORDER

CHRISTOPHER A. BOYKO, District Judge.

This matter is before the Court on Plaintiff Angel Jet Services, LLC’s (“AJS”) and Defendant Cleveland Clinic Employee Health Plan Total’s respective briefs requesting Judgment on the Administrative Record. The parties seek judgment on AJS’s claim it was unlawfully denied benefits in violation of the Employ[781]*781ee Retirement Income Standards Act (“ERISA”). For the following reasons, the Court finds Plaintiff lacks standing to pursue ERISA claims against Defendant and grants judgment for Defendant on Plaintiffs claims.

Background Facts

Plaintiff Angel Jet Services, LLC (“AJS”) is an air ambulance company that transports patients from one medical facility to another while providing in-transit medical care, including critical care nurses. On July 7, 2010, AJS transported J.S., the minor child of Dr. Jason Springer (“Springer”) from Utah to Cleveland, Ohio, where Springer had recently accepted a residency with the Cleveland Clinic. As an employee of the Cleveland Clinic, Springer was a participant under the Cleveland Clinic’s Employee Health Plan Total Care (“Plan”) and J.S. was covered under the Plan as well. According to Plaintiff, Springer attempted to obtain pre-approval for coverage of the costs of AJS’s air ambulance services in transporting his child to Cleveland but failed to obtain pre-approval. After the transport, AJS submitted a bill for its services totaling $340,100 to the Plan’s administrator, Antares Management Solutions, Inc. (“Antares”). AJS alleges it was assigned Springer’s rights under the Plan for payment. Antares initially informed Plaintiff that the claim was approved, however, it later denied payment, contending Springer never obtained pre-approval before engaging the services of AJS. Ultimately, the Plan paid for only ten percent of AJS’s bill.

AJS challenges the decision of the Plan Administrator and seeks full payment under the Plan.

Defendant argues AJS lacks standing to assert claims and seek reimbursement from Defendant. Furthermore, Defendant argues the Plan Administrator correctly determined that Plaintiff is not entitled to full payment because the covered employee failed to obtain preapproval under the plain terms of the Plan.

Standard of Review

The Court applies the arbitrary and capricious standard of review where a policy cloaks the plan administrator with the discretionary authority to determine eligibility and construe the terms of a policy. DeLisle v. Sun Life Assurance Co. of Canada, 558 F.3d 440 (6th Cir.2009) (Citing Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989)). The arbitrary and capricious standard is the most deferential form of judicial review. Admin. Comm. of Sea Ray Employees’ Stock Ownership and Profit Sharing Plan v. Robinson, 164 F.3d 981, 989 (6th Cir.1999). The administrator’s decision should be upheld if it is “the result of a deliberate, principled reasoning process” and “supported by substantial evidence.” Glenn v. Metro. Life Ins. Co., 461 F.3d 660, 666 (6th Cir.2006), aff'd, 554 U.S. 105, 128 S.Ct. 2343, 171 L.Ed.2d 299 (2008). The court must consider several factors, including the quality and quantity of medical evidence and the policy administrator’s consideration of the Social Security Administrator’s determination. Glenn, 461 F.3d at 666. A possible conflict of interest due to the administrator’s dual role is “but one factor among many that a reviewing judge must take into account.” Glenn, 128 S.Ct. at 2351. Ultimately, the Court must determine whether the plan administrator’s decision was rational. Calvert v. Firstar Fin., Inc., 409 F.3d 286, 295 (6th Cir.2005).

In denying Plaintiffs Motion for Discovery, the Court determined the Plan Administrator had discretionary authority to determine eligibility and construe the terms of the Policy. Therefore, the Court determined the proper standard of review [782]*782to be applied is the arbitrary and capricious standard.

According to Plaintiff, Defendant breached its duty under the Plan when it paid Angel Jet only a fraction of-its billed charges for transporting J.S. J.S. is the child of Athena and Dr. Jason Springer. J.S. was born on May 4, 2009, with severe congenital abnormalities. In the spring of 2010, Springer accepted a position with the Cleveland Clinic beginning on July 1, 2010. The new position involved Springer moving his wife and child from Utah to Cleveland, Ohio. Due to J.S.’s medical condition, the move required medical transport. On July 1, 2010, Springer enrolled himself, Athena and J.S. in Defendant’s health plan. The Plan contains the following language:

Coverage-Effective Date

As long as you have enrolled in the health plan within 31 days of your start date, your coverage is effective on the first day you actively start to work. It takes. approximately 15 business days from the time your paperwork is received by Human Resources to the time your benefit selection is processed with the TPA. If you require services prior to your benefit being processed, your claims may be denied. These claims will be adjusted on the backend when the TPA processes your benefit selections data.

According to Plaintiff, Springer attempted to obtain pre-approval for the flight but Defendant’s third party administrator was unable to confirm that Springer was covered under Defendant’s Plan. Plaintiff had J.S. flown to Cleveland utilizing Plaintiffs services. AJS attempted to assert its right to payment pursuant to an assignment it obtained from Springer but payment was ultimately reduced to approximately ten percent of AJS’s billed charges.

Defendant argues Plaintiff lacks standing because the only assignment in the Administrative Record is an assignment of Springer’s wife, Athena, to AJS. That assignment predates Springer’s employment with the Cleveland Clinic and coverage under the Defendant’s Plan. The assignment in the Administrative Record was executed on June 8, 2010. Springer was not a covered insured under Defendant’s Plan until July 1, 2010. Therefore, according to Defendant, Athena had no vested right in the Defendant’s Plan that she could assign to AJS at the time the assignment was made.

AJS contends it has the right to pursue reimbursement from Defendant under the assignment. According to AJS, it was an assignee of Springer’s and J.S.’s rights, including the right to reimbursement, under Defendant’s Plan.

The assignment in the Administrative Record belies the allegations in Plaintiffs Complaint. According to Plaintiffs Complaint “At all relevant times, AJS was an assignee of Springer and J.S. pursuant to an assignment of benefits assigning all Plan benefits relating to this claim to AJS. Thus, AJS “stands in the shoes” of Springer and J.S.

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34 F. Supp. 3d 780, 59 Employee Benefits Cas. (BNA) 1259, 2014 WL 3615798, 2014 U.S. Dist. LEXIS 98784, Counsel Stack Legal Research, https://law.counselstack.com/opinion/angel-jet-services-llc-v-cleveland-clinic-employee-health-plan-total-care-ohnd-2014.