Mercy Hospital of Folsom v. Health Care Service Corporation

CourtDistrict Court, N.D. Illinois
DecidedJuly 2, 2024
Docket1:24-cv-02749
StatusUnknown

This text of Mercy Hospital of Folsom v. Health Care Service Corporation (Mercy Hospital of Folsom v. Health Care Service Corporation) is published on Counsel Stack Legal Research, covering District Court, N.D. Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Mercy Hospital of Folsom v. Health Care Service Corporation, (N.D. Ill. 2024).

Opinion

UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION Mercy Hospital of Folsom,

Plaintiff, No. 24 CV 2749 v. Judge Lindsay C. Jenkins Health Care Service Corporation, et al.

Defendants.

MEMORANDUM OPINION AND ORDER Mercy Hospital of Folsom (“Mercy”) sued Health Care Service Corporation (“HCSC”) in Illinois state court alleging HCSC failed to adequately compensate it for services it rendered to eight patients with HCSC-sponsored health plans.1 HCSC timely removed the case to this Court arguing federal question and supplemental jurisdiction exist because one of the patients has a health plan that is governed by the Employee Retirement Income Security Act (“ERISA”). Mercy now seeks remand. For the following reasons, the motion is denied with respect to the claim involving the ERISA plan. The Court declines, however, to exercise supplemental jurisdiction over the claims related to the remaining seven disputes. I. Background Mercy is a California-based public benefit corporation that provides medical care to patients. [Dkt. 1-1 ¶ 3.] Mercy has a contract with Blue Cross of California whereby Mercy agrees to provide medical treatment to individuals with health plans

1 Mercy also sued a series of “Doe” Defendants whose identities are currently unknown. [Dkt. 1-1.] “financed, sponsored, and/or administered” by HCSC at set rates. [Id. ¶ 27.] HCSC is not a signatory to this contract, but Mercy contends the parties have an implied-in- fact contractual relationship where Mercy agrees to treat HCSC’s insureds, and

HCSC agrees to reimburse Mercy at the contract price. [Id. ¶¶ 28-31.] Between May 9, 2018, and April 12, 2021, Mercy provided various treatments to eight patients with HCSC health plans. [Id. ¶¶ 11-12.] The aggregate market rate for these treatments was $1,095,551.61, but pursuant to the contract rates, Mercy billed HCSC $648,130.72. [Id. ¶ 34.] To date, HCSC has only paid Mercy $274,160, leaving a balance of $373,970.72. [Id.] Despite demands from Mercy, HCSC has

refused to make additional payments. This litigation followed. Mercy sued HCSC in Cook County alleging HCSC breached the parties’ implied-in-fact contract by refusing to pay the contract rates for the services, or, alternatively, owes Mercy under a quantum meruit theory. HCSC timely removed the case to federal court. HCSC contends that because one of the eight patients, “Patient No. 5” (the “Patient”), has a healthcare plan governed by ERISA, federal law completely preempts the claim.2 [Dkt. 1 at 3.]3

The Patient’s plan articulates when HCSC must pay for services: “All services and supplies for which benefits are available under the Plan must be Medically

2 HCSC relies on declarations from Jo McMillin to substantiate its claim that the Patient’s plan is governed by ERISA and for various other issues. [Dkt. 1 at 4-5; Dkt. 1-3; Dkt. 35-1.] Because this motion involves whether the Court has subject-matter jurisdiction, it may consider such evidence. See John Muir Health v. Health Care Serv. Corp., 2023 WL 4707430, at *3 n.1 (N.D. Ill. July 24, 2023). 3 Citations to docket filings generally refer to the electronic pagination provided by CM/ECF, which may not be consistent with page numbers in the underlying documents. Necessary as determined by [HCSC]. Charges for services and supplies which [HCSC] determines are not Medically Necessary will not be eligible for benefit consideration.” [Dkt. 26 at 9.] The plan includes a lengthy definition for what constitutes “Medically

Necessary”, but at a high level, the treatment must be “essential” to a patient’s condition, provided in a generally accepted and economical manner, and not for the benefit of the provider. [See Dkt. 1-4 at 82-83.] The parties agree HCSC has refused to pay for any treatment Mercy provided the Patient on the basis it was not Medically Necessary. [Dkt. 1-1 at 27; Dkt. 26 at 7, 9.] Prior to treating the Patient, Mercy contacted HCSC, informed it of the Patient’s

hospitalization and sent a pre-authorization request. [Dkt. 33 at 4-5; Dkt. 35 at 3.] In response, HCSC provided a “pended authorization number”, which informs the provider that HCSC will require additional information before deeming the treatment Medically Necessary. [Dkt. 35 at 3.] Mercy treated the Patient before receiving confirmation from HCSC that it would pay for the treatments.4 [Id. at 4.] Based on these facts, HCSC argues Mercy’s claim derives from the benefits prescribed in the Patient’s ERISA plan, and so ERISA preempts the claim.

Essentially, the Court (and ultimately a jury) will need to analyze the plan language—and particularly the plan’s definition of Medically Necessary—as compared to the Patient’s treatment to determine HCSC’s payment obligations. [Dkt. 1 at 9-10.] And because the Court has jurisdiction over the Patient, it has

4 The parties dispute whether HCSC pre-authorized treatment, but based on the Court’s review of the parties’ submissions, it appears conclusive there is no evidence of pre- authorization. [Dkt. 35-1.] supplemental jurisdiction over the claims related to the remaining seven patients under 28 U.S.C. § 1367(a). [Id. at 13-15.] Mercy now moves to remand. II. Analysis

A defendant may remove an action filed in state court when the action could have been brought in federal court. 28 U.S.C. § 1441(a). A federal court has jurisdiction over claims “arising under the Constitution, laws, or treaties of the United States.” 28 U.S.C. § 1331. “As the party seeking removal, [HCSC] bears the burden of establishing federal jurisdiction.” Tri-State Water Treatment, Inc. v. Bauer, 845 F.3d 350, 352 (7th Cir. 2017). To determine whether a complaint arises under federal law, courts employ the

“well-pleaded complaint rule.” Citadel Sec., LLC v. Chi. Bd. Options Exch., Inc., 808 F.3d 694, 701 (7th Cir. 2015). This rule “provides that federal jurisdiction exists only when a federal question is presented on the face of the plaintiff’s properly pleaded complaint.” Id. That is, “the plaintiff’s statement of his own cause of action” must show “that it is based upon federal law.” Vaden v. Discover Bank, 556 U.S. 49, 60 (2009).

But “a plaintiff may not defeat removal by omitting to plead necessary federal questions”, which occurs when a plaintiff does not plead a federal cause of action, even though “federal law completely preempts a plaintiff’s state-law claim.” Citadel Sec., 808 F.3d 694 at 701. “Complete preemption, really a jurisdictional rather than a preemption doctrine, confers exclusive federal jurisdiction in certain instances where Congress intended the scope of a federal law to be so broad as to entirely replace any state-law claim.” Franciscan Skemp Healthcare, Inc. v. Cent. States Joint Bd. Health & Welfare Tr. Fund, 538 F.3d 594, 596 (7th Cir. 2008). “The ERISA civil enforcement mechanism is one of those provisions with such extraordinary pre- emptive power that it converts an ordinary state common law complaint into one

stating a federal claim for purposes of the well-pleaded complaint rule.” Id.

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Mercy Hospital of Folsom v. Health Care Service Corporation, Counsel Stack Legal Research, https://law.counselstack.com/opinion/mercy-hospital-of-folsom-v-health-care-service-corporation-ilnd-2024.