Grasso Enters., LLC v. CVS Health Corp.

143 F. Supp. 3d 530, 2015 U.S. Dist. LEXIS 145975, 2015 WL 6550548
CourtDistrict Court, W.D. Texas
DecidedOctober 28, 2015
DocketCivil No. SA-15-CV-427-XR
StatusPublished
Cited by8 cases

This text of 143 F. Supp. 3d 530 (Grasso Enters., LLC v. CVS Health Corp.) is published on Counsel Stack Legal Research, covering District Court, W.D. Texas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Grasso Enters., LLC v. CVS Health Corp., 143 F. Supp. 3d 530, 2015 U.S. Dist. LEXIS 145975, 2015 WL 6550548 (W.D. Tex. 2015).

Opinion

ORDER

XAVIER RODRIGUEZ, District Judge.

On this date, the Court considered Defendants CVS Health Corporation, Care-mark, LLC, and CaremarkPCS Health, LLC’s Motion to Dismiss and Compel Arbitration (docket no. 44) and each party’s subsequent responses (docket nos. 23, 24, 42, and 43). The Court also considered Plaintiff Grasso Enterprises, LLC’s Motion for Preliminary Injunction (docket no. 26) and the subsequent responses (docket nos. 33, 42, and 43). After careful consideration, the Court will GRANT IN PART and DENY IN PART Defendant’s Motion to Dismiss and Compel Arbitration and DISMISS AS MOOT Plaintiffs Motion for Preliminary Injunction.

FACTUAL BACKGROUND

I. The relationship between the parties

Plaintiff Grasso Enterprises (“Grasso”) owns two compounding pharmacies — one in Boeme, Texas and one in Kerrville, Texas. Docket no. 1 at 2. Both pharmacies are “innetwork” pharmacies with Defendants CVS Health Corporation, Caremark, LLC, and CaremarkPCS Health, LLC (“CVS/Caremark”). Id. at 3.

The relationship between the two parties is governed by two agreements. In 2008, Grasso entered into a Provider Agreement with CVS/Caremark with respect to the pharmacy located in Boerne. Docket no. 44-2. Then, in 2014 Grasso entered into another Provider Agreement with respect to the pharmacy located in. Kerrville. Docket no. 44-3. Both agreements are signed by Dr. Leigh Ann Gras-so, an agent of Grasso, and an agent of CVS/Caremark. Docket nos. 44-2, 44-3. [534]*534Both agreements incorporated by reference the terms of another document — the Provider Manual. Id.

The Provider Manual contains a provision that allows CVS/Caremark to amend the manual by giving the pharmacies notice of the terms of the amendment and specifying the date the amendment becomes effective. Docket no. 23 at 2. The provision also states that submitting claims to CVS/Caremark after the effective date of the amendment constitutes acceptance of the changes on the part of the pharmacy. Id. The Provider Manual has been revised in this manner a handful of times since 2008. Smith Dec. ¶ 11. Each time this occurs, a copy of the new Provider Manual is sent to all pharmacies. Id.

Each version of the Provider Manual provided to the Court contained an arbitration clause. See Pre. Inj. Hearing Plaintiffs Ex. A at 44; docket no. 44-4 at 37; docket no. 44-5 at 43; docket no. 44-6 at 50; docket no. 44-7 at 45. The most recent version of the Provider Manual governs this dispute. Grasso acknowledges that it received this version of the Manual when the Kerrville location joined the CVS/Caremark network in 2014. Pre. Inj. Hearing Trans, at 111. This version of the Provider Manual’s arbitration provision states in relevant part:

Any and all disputes between Provider and Caremark (including Caremark’s employees, parents, subsidiaries, affiliates, agents and assigns (collectively referred to in this Arbitration section as “Caremark”) [) ], including but not limited to disputes in connection with, arising out of, or relating in any way to, the Provider Agreement or to Provider’s participation in one or more Caremark networks or exclusion from any Care-mark networks, will be exclusively settled by arbitration. Unless otherwise agreed to in writing by the parties, the arbitration shall be administered by the American Arbitration Association (“AAA”) pursuant to the then applicable AAA Commercial Arbitration Rules and Mediation Procedures (available from the AAA).
Arbitration with respect to a dispute is binding and neither Provider nor Caremark will have the right to litigate that dispute through a court. In arbitration, Provider and Caremark will not have the rights that are provided in court, including the right to a trial by judge or jury. In addition, the right to discovery and the right to appeal are limited or eliminated by arbitration. All of these rights are waived and disputes must be resolved through arbitration.
The above notwithstanding, nothing in this provision shall prevent either party from seeking preliminary injunction relief to halt or prevent a breach of this Provider Agreement in any state or federal court of law.
The terms of this arbitration section apply notwithstanding any other or contrary provision of the Provider Agreement, including, but not limited to, any contrary language in any Third Party Beneficiary provision. This Arbitration section survives the termination of this Provider Agreement and the completion of the business- relationship between Provider and Caremark. This arbitration is made pursuant to a transaction involving interstate commerce, and shall be governed by the Federal Arbitration Act, 9 U.S.C. §§ 1-16.

Docket no. 44-7 at 45-46 (emphasis in original).

[535]*535II. The dispute that led to this suit

Grasso filed suit in this Court on May 22, 2015. Docket no. 1. Grasso seeks monetary damages and a variety of declaratory and injunctive relief. See docket no. 25. Grasso claims that CVS/Caremark’s procedures for processing claims violate the Employee Retirement Income Security Act (ERISA), the Patient Protection and Affordable Care Act (PPACA), and a U.S. Department of Labor regulation, 29 C.F.R. § 2560.503-1 (“Claims Regulation”) that applies to both ERISA and PPACA. Docket no. 25 at 3. The Claims Regulation gives CVS/Caremark 30 days to pay, deny, or make inquiries on a group health benefits plan. 29 C.F.R. § 2560.503-1.

Grasso contends in its amended complaint (docket no. 25) that it is the practice of CVS/Caremark to not review claims, but to instead use a computerized automated system to process all claims, which creates an appearance of compliance with the Claims Regulation’s 30-day time frame. Docket no. 25 at 4. But Grasso alleges that CVS/Caremark’s practice is to choose to review claims that the automated system has previously approved after the 30-day period is over. M They supposedly do this by contacting pharmacies about previously approved claims and demanding reimbursements for amounts they previously paid to the pharmacy. Id. Grasso also contends that CVS/Caremark forcibly take back the money by withholding current and future claim payments that they owe the pharmacy under other, unrelated health plans. Id. at 9. Essentially, Grasso complains that CVS/Caremark unlawfully reserve unto themselves the ability to “untimely review and reverse claim decisions long after the statutorily mandated 30-day time window has closed” and then withholds other, unrelated money they owe Grasso to enforce this. Id. at 4, 9. Grasso also alleges in its amended complaint that CVS/Caremark have unilaterally purported to amend the in-network provider contract they entered into with Grasso and other pharmacies in a manner that affects the pharmacies’ right to reimbursement. Id. at 6.

However, in their motion to dismiss and compel arbitration, CVS/Caremark tell a different story. Docket no. 44 at 5-9. They allege that they undertook a lawful audit of Grasso’s two pharmacies — one that they were entitled to conduct based on the parties contracts with one another.

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143 F. Supp. 3d 530, 2015 U.S. Dist. LEXIS 145975, 2015 WL 6550548, Counsel Stack Legal Research, https://law.counselstack.com/opinion/grasso-enters-llc-v-cvs-health-corp-txwd-2015.