Hackney v. AllMed Healthcare Management Inc.

679 F. App'x 454
CourtCourt of Appeals for the Sixth Circuit
DecidedFebruary 17, 2017
Docket16-5651
StatusUnpublished
Cited by4 cases

This text of 679 F. App'x 454 (Hackney v. AllMed Healthcare Management Inc.) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Hackney v. AllMed Healthcare Management Inc., 679 F. App'x 454 (6th Cir. 2017).

Opinions

OPINION

JANE B. STRANCH, Circuit Judge.

James Hackney was covered by a disability policy through his employer and, due to his declining medical condition, filed a claim for long-term disability insurance benefits. The insurance carrier sent his medical records to a third-party reviewer, AllMed, for a medical opinion on whether Hackney’s records supported a finding of total disability. Upon receiving AllMed’s opinion that Hackney was not disabled, the insurance carrier denied his claim. Hackney subsequently brought this state-law claim against AllMed, which removed the case to federal court alleging complete [456]*456preemption under the Employee Retirement Income Security Act of 1974 (ERISA). Hackney appeals the district court’s denial of his motion to remand the case to state court and its grant of AllMed’s motion to dismiss his case. Applying our precedent to the facts in this record, we AFFIRM.

I. BACKGROUND

Hackney worked in Kentucky as an associate account manager, and then director of marketing, for Vascular Solutions, Inc. (VSI), a Minnesota-based company. Hackney v. Lincoln Nat'l Life Ins. Co., 657 Fed.Appx. 563, 566 (6th Cir. 2016). Through his employment, Hackney was covered by a group long-term disability insurance policy that was financed by VSI and administered by Lincoln National Life Insurance Company (Lincoln). Id. at 567. In October 2010, Hackney’s medical condition of hypoparathyroidism made it so he could no longer work. Id. He took medical leave and applied to Lincoln for benefits provided by his employer-furnished insurance policy. Lincoln engaged AllMed, an Oregon-based third-party record reviewer, to evaluate Hackney’s medical documents and provide an opinion on whether the medical evidence supported Hackney’s claim of complete disability. AllMed opined that Hackney was able to work:

Based on a review of the additional medical records, the claimant does not appear to have any impairments that would translate into restrictions or limitations ... The restrictions and limitations that were placed upon the claimant’s work activities by [Hackney’s treating physicians] are not consistent with the additional medical records.

(R. 1-1, PagelD 12).

AllMed’s opinion was drafted and revised by its agents Robert J. Cooper and Skip Freedman. Neither AllMed nor its agents were licensed to practice medicine in Kentucky at the time they reviewed Hackney’s records and rendered their opinion on Hackney’s medical status. Based in part on AllMed’s opinion, Hackney’s claim for disability benefits was denied. Due to the same medical condition, however, Hackney was granted disability benefits through a separate private insurance plan. Additionally, the Social Security Administration determined Hackney to be totally and permanently disabled effective October 2010. Hackney, 657 Fed.Appx. at 568.

Hackney filed a lawsuit, separate from this one, against VSI and Lincoln in Kentucky state court that included claims for breach of contract, breach of the duty of good faith and fair dealing, and the unlicensed practice of medicine in connection with the denial of his application for short-term disability benefits under his employer-sponsored plan. Id. at 569. The unlicensed practice claim alleged violation of Kentucky law by “employing unlicensed, out-of-state nurses to review his application for benefits.” Id. at 579. The case was removed to federal court on the basis of diversity jurisdiction, where summary judgment was granted to the defendants on all claims. On appeal, we reversed and remanded to the finder of fact on the claims for breach of contract and the duty of good faith and fair dealing. Id. We affirmed on the unlicensed practice of medicine claim, finding that the nurses’ review of Hackney’s file did not fall within the state statute governing the practice of medicine. Id.

Hackney filed this lawsuit against AllMed in state court alleging a state-law violation relating to AllMed’s “actions in rendering an unlicensed medical opinion” concerning Hackney, The medical opinion was requested by Lincoln, who was reviewing Hackney’s request for long-term [457]*457disability benefits under the ERISA-based insurance plan that it administered for VSI employees. AllMed removed the case to federal court based on complete preemption under ERISA. The trial court denied Hackney’s motion to remand the case to state court and granted AllMed’s motion to dismiss under Rule 12(b)(6). .Hackney timely appealed the final judgment against him.

II. ANALYSIS

A. Standard of Review

We review de novo a district court’s decision involving legal questions of subject matter jurisdiction. Hogan v. Jacobson, 823 F.3d 872, 879 (6th Cir. 2016). Factual determinations regarding jurisdictional matters are reviewed for clear error. Id. A district court’s ruling on a motion to dismiss a claim is reviewed de novo. Id. at 883.

B. Complete Preemption of State-Law Claims under ERISA

The Supreme Court has articulated a two-prong test to determine whether a claim is completely preempted under § 1132(a) of ERISA. Aetna Health Inc. v. Davila, 542 U.S. 200, 210, 124 S.Ct. 2488, 159 L.Ed.2d 312 (2004). A claim is completely preempted when it satisfies both prongs of the following test:

(1) the plaintiff complains about the denial of benefits to which he is entitled only because of the terms of an ERISA-regulated employee benefit plan; and (2) the plaintiff does not allege the violation of any legal duty (state or federal) independent of ERISA or the plan terms.

Gardner v. Heartland Indus. Partners, LP, 715 F.3d 609, 613 (6th Cir. 2013) (quoting Davila, 542 U.S. at 210, 124 S.Ct. 2488). The state-law claims in Davila involved insurance plans failing to exercise ordinary care when the plans denied coverage for certain medical procedures. Davila, 542 U.S. at 204-05, 124 S.Ct. 2488. Those claims involved “pure eligibility decisions” and were preempted by ERISA. Id. at 221, 124 S.Ct. 2488.

1. Claims Based on the Terms of an ERISA-Regulated Plan

To determine whether a claim satisfies the first prong of the Davila test, courts look beyond the “label placed on a state law claim” and instead ask “whether in essence such a claim is for the recovery of an ERISA benefit plan.” Hogan, 823 F.3d at 880 (quoting Peters v. Lincoln Elec. Co., 285 F.3d 456, 469 (6th Cir. 2002)). A claim “likely falls within the scope of § 1132 when the only action complained of is a refusal to provide benefits under an ERISA plan and the only relationship between the plaintiff and defendant is based on the plan.” Id. (quoting Davila, 542 U.S. at 211, 124 S.Ct. 2488).

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679 F. App'x 454, Counsel Stack Legal Research, https://law.counselstack.com/opinion/hackney-v-allmed-healthcare-management-inc-ca6-2017.