Grand Traverse Band of Ottawa & Chippewa Indians v. Blue Cross & Blue Shield of Mich.

391 F. Supp. 3d 706
CourtDistrict Court, E.D. Michigan
DecidedMay 20, 2019
DocketCase No. 14-cv-11349
StatusPublished
Cited by2 cases

This text of 391 F. Supp. 3d 706 (Grand Traverse Band of Ottawa & Chippewa Indians v. Blue Cross & Blue Shield of Mich.) is published on Counsel Stack Legal Research, covering District Court, E.D. Michigan primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Grand Traverse Band of Ottawa & Chippewa Indians v. Blue Cross & Blue Shield of Mich., 391 F. Supp. 3d 706 (E.D. Mich. 2019).

Opinion

JUDITH E. LEVY, United States District Judge *710In its earlier stages, this case was about claims brought under the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001 ; now, this case is about state law violations regarding non-employee group health insurance. Plaintiffs, the Grand Traverse Band of Ottawa and Chippewa Indians ("the Tribe") and its Employee Welfare Plan ("the Plan") raise EIRSA, state law breach of contract, Michigan's Health Care False Claims Act ("HCFCA"), Mich. Comp. Laws § 752.1001, common law fiduciary duty, and other common law tort claims against defendant Blue Cross Blue Shield of Michigan ("BCBSM"), the Plan administrator. Previously, the Court rejected all of plaintiffs' claims except its breach of contract claim, in part because the parties agreed that the breach of common law fiduciary duty and the HCFCA claims were preempted by ERISA. However, the parties agreed to reinstate the common law fiduciary duty and HCFCA claims in the wake of the Sixth Circuit's decision in Saginaw Chippewa Indian Tribe of Mich. v. Blue Cross Blue Shield of Mich. , 748 F. App'x 12 (6th Cir. 2018). Before the Court is defendant's motion to dismiss those two claims.

I. Background

The Court provided a complete factual background of the underlying claims in its previous opinion and order granting in part and denying in part defendant's motion to dismiss, which it reincorporates fully here. (Dkt. 99 at 2-6.) For clarity, the Court summarizes the background and notes new developments in the case's procedural history.

The Tribe is federally-recognized. The Tribe maintains a self-funded employee welfare plan, the Plan, which covers three groups of participants: members of the Tribe who are employed by the Tribe (Group #01010); members of the Tribe who are not employed by the Tribe (Group #01020); and employees of the Tribe who are not members of the Tribe (#48571). BCBSM has been the Plan administrator since 2000. (Dkt. 90-2 at 3.)

In 2007, new federal regulations went into effect which provided that "[a]ll Medicare-participating hospitals ... must accept no more than the rates of payment under the methodology described in this section as payment in full for all terms and services authorized by [Indian Health Service], Tribal, and urban Indian organization entities," and even if the parties had negotiated different rates, tribes would "pay the lesser of" the amount determined by the methodology and the negotiated amount. 42 C.F.R. §§ 136.30(a), (f). These are known as the "Medicare-Like Rates" ("MLR") regulations.

Plaintiffs allege that they asked BCBSM to ensure that they were receiving MLR for the Tribe member groups, Groups #01019 and #01020. (Dkt. 90 at 14). BCBSM claimed that "it could not adjust its entire system to calculate MLR on those claims eligible for MLR discounts," but could provide a rate that would be close to MLR by providing a discount for plaintiffs' claims for services at the Munson Medical Center to Group #01020, the non-employee Tribe members. (Id. at 15.) This led the parties to enter into the Facility *711Claims Process Agreement ("FCPA") with Munson Medical Center, effective on March 1, 2009. (Dkt. 90 at 6; Dkt. 90-4.) However, in 2012, plaintiffs obtained a third-party audit and discovered that they were "not paying anything 'close to MLR' on claims." (Dkt. 90 at 16.) They state that they "did not discover the full extent of BCBSM's" conduct until 2013. (E.g. , id. at 19.)

Plaintiffs filed their first complaint on April 1, 2014. (Dkt. 1.) On January 24, 2019, plaintiffs were permitted to file an amended complaint, alleging breach of fiduciary duty under ERISA, violations of the HCFCA, breach of contract and the covenant of good faith and fair dealing in the alternative, breach of common law fiduciary duty, fraud and misrepresentation, and silent fraud. (Dkt. 90.) BCBSM filed a motion to dismiss those claims (Dkt. 94), which the Court granted in part and denied in part. (Dkt. 99.) The Court dismissed all claims except for the breach of contract claim, noting that the parties agreed that the breach of common law fiduciary duty and HCFCA claims were preempted by ERISA. (Id. at 22, 25.) Plaintiffs filed a motion for reconsideration (Dkt. 101) and a motion to file a second amended complaint (Dkt. 102), and both were denied. (Dkt. 107.)

In August 2018, the Sixth Circuit held that the Saginaw Chippewa Indian Tribe of Michigan's Welfare Benefit Plan was not an ERISA plan when it covered non-employee Tribe members. Saginaw Chippewa Indian Tribe of Mich. v. Blue Cross Blue Shield of Mich. , 748 F. App'x 12, 19 (6th Cir. 2018). Because this undermined the parties' previous agreement that all claims for violations of HCFCA and breach of common law fiduciary duty were preempted by ERISA, the parties agreed to reinstate those claims as to Group #01020, the non-employee Tribe members, for the purpose of testing that legal theory in this case. (Dkt. 116.) The motion to dismiss before the Court followed (Dkt. 117) and is now fully briefed.1 (Dkts. 119, 120.)

II. Legal Standard

When deciding a motion to dismiss under Federal Rule of Procedure 12(b)(6), the Court must "construe the complaint in the light most favorable to the plaintiff and accept all allegations as true." Keys v. Humana, Inc., 684 F.3d 605, 608 (6th Cir. 2012). "To survive a motion to dismiss, a complaint must contain sufficient factual matter, accepted as true, to state a claim to relief that is plausible on its face." Ashcroft v. Iqbal , 556 U.S. 662, 678, 129 S.Ct. 1937, 173 L.Ed.2d 868 (2009). A plaintiff's claim is facially plausible "when the plaintiff pleads factual content that allows the court to draw the reasonable inference that the defendant is liable for the misconduct alleged."

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Bluebook (online)
391 F. Supp. 3d 706, Counsel Stack Legal Research, https://law.counselstack.com/opinion/grand-traverse-band-of-ottawa-chippewa-indians-v-blue-cross-blue-mied-2019.