United States Ex Rel. Stinson, Lyons, Gerlin & Bustamante, P.A. v. Blue Cross Blue Shield of Georgia, Inc.

755 F. Supp. 1040, 1990 U.S. Dist. LEXIS 18719, 1990 WL 255660
CourtDistrict Court, S.D. Georgia
DecidedOctober 18, 1990
DocketCV 489-224
StatusPublished
Cited by41 cases

This text of 755 F. Supp. 1040 (United States Ex Rel. Stinson, Lyons, Gerlin & Bustamante, P.A. v. Blue Cross Blue Shield of Georgia, Inc.) is published on Counsel Stack Legal Research, covering District Court, S.D. Georgia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
United States Ex Rel. Stinson, Lyons, Gerlin & Bustamante, P.A. v. Blue Cross Blue Shield of Georgia, Inc., 755 F. Supp. 1040, 1990 U.S. Dist. LEXIS 18719, 1990 WL 255660 (S.D. Ga. 1990).

Opinion

ORDER

EDENFIELD, Chief Judge.

The defendant, Blue Cross Blue Shield of Georgia (“BC-GA”) has moved to dismiss this action, questioning the Court’s subject-matter jurisdiction under the qui tam provisions of the False Claims Act, 31 U.S.C. §§ 3729-31 (1988) [hereinafter “FCA”], as amended by the False Claims Act Amendments of 1986, Pub.L. No. 99-562,100 Stat. 3153 (1986) [hereinafter “FCA Amendments”]. In addition, BC-GA moves to dismiss, or, in the alternative, for a more definite statement, on the ground that the qui tam plaintiff, Stinson, Lyons, Gerlin, & Bustamante, P.A. (“Stinson Lyons”), has not pleaded its allegations of fraud with the particularity required by Fed.R.Civ.P. 9(b). The jurisdictional issue presents, among other things, a question of statutory construction. The Court does not find BC-GA’s jurisdictional arguments persuasive. The Court agrees with BC-GA, however, that Stinson Lyons has not pleaded its complaint with the required particularity. For reasons developed in more detail below, the Court DENIES BC-GA’s motion to dismiss, and GRANTS BC-GA’s motion for a more definite statement.

BACKGROUND

A. Facts and Procedural History

Stinson Lyons has brought this suit against BC-GA, alleging that BC-GA has defrauded the government by shifting responsibility for the payment of insurance claims to Medicare when, under section 116(a) of the Tax Equity and Fiscal Responsibility Act of 1982 (“TEFRA”), it should not have done so. When workers aged 65-69 (“the working aged”) enjoy both Medicare and an employer group health coverage plan, and are still working when they receive benefits, TEFRA requires that Medicare remain the secondary insurer, and that the private insurer pay primary. Stinson Lyons alleges that BC-GA knew of and understood its contractual and legal obligations under TEFRA, but nevertheless tricked Medicare into paying as a primary insurer when BC-GA should have paid primary. The effect of these actions, says Stinson Lyons, was that BC-GA ended up paying out much less than it should have, at the taxpayers’ expense, in situations where an insured was covered both by Medicare and private insurance under BC-GA. According to the complaint, BC-GA also concealed and avoided its responsibility to Medicare under TEFRA in certain other situations.

*1044 How Stinson Lyons came to learn of this alleged fraud is important to the resolution of whether the Court has subject matter jurisdiction. Several years ago, Stinson Lyons represented a Mr. Leonard in an action brought by Mr. Leonard to redress injuries he sustained in a car crash. Provident Life & Accident Insurance Co. v. Leonard, No. 85-10113 CA(15) (Fla. Dade Co. Cir.Ct. March 1985), rev’d, 526 So.2d 721 (Fla.Dist.Ct.App.1988) (“the Leonard litigation”). During the course of the Leonard litigation, Stinson Lyons became aware of what it considered to be illegal claims handling practices of Mr. Leonard’s insurer, Provident Life & Accident Insurance Company (“Provident”). Through discovery in the Leonard litigation, Stinson Lyons obtained internal corporate memo-randa from Provident. One of these mem-oranda addressed Provident’s method of processing claims for the working aged. The memorandum recommended changing the procedure to comply with Medicare regulations promulgated in the wake of TEFRA. Another, entitled “Policy Issue, Medicare Reimbursement,” discussed several alternative methods of coordinating the payment of medical benefits between Provident and Medicare. That document contains a list of nine insurance carriers supposedly contacted by Provident, and next to the names of three carriers is the phrase “Same as us.” One of the three is the defendant BC-GA. Stinson Lyons argues that this phrase indicates that someone at BC-GA admitted to someone at Provident that BC-GA is also defrauding the government in precisely the same way as Provident.

Stinson Lyons instituted a qui tam action against Provident based on the documents it acquired in the Leonard litigation. See United States ex rel. Stinson, Lyons, Gerlin & Bustamante, P.A. v. Provident Life & Accident Ins. Co., 721 F.Supp. 1247 (S.D.Fla.1989) (“the Provident litigation”). Subsequently, armed only with the notation “Same as us,” Stin-son Lyons filed identical qui tam actions against BC-GA and the other two carriers mentioned. See United States ex rel. Stinson, Lyons, Gerlin & Bustamante, P.A. v. Prudential Ins. Co. of Am., 736 F.Supp. 614 (D.N.J.1990); United States ex rel. Stinson, Lyons, Gerlin & Bustamante, P.A. v. Pan American Life Ins. Co., No. 90-411 (E.D.La.).

B. The FCA Generally

The purpose of the FCA is to recover money fraudulently taken from the government. E.g., United States ex rel. Houck v. Folding Carton Admin. Comm., 881 F.2d 494, 504 (7th Cir.1989) (citing United States ex rel. Marcus v. Hess, 317 U.S. 537, 551, 63 S.Ct. 379, 387, 87 L.Ed. 443 (1943)), cert. denied, — U.S. -, 110 S.Ct. 1471, 108 L.Ed.2d 609 (1990) [hereinafter “Houck” ]. The FCA provides that, under certain circumstances, a private party— called a qui tam plaintiff or private citizen relator — may bring an action on the United States’s behalf to recover fraudulently taken funds. Houck, 881 F.2d at 504; see Avco Corp. v. United States Dep’t of Justice, 884 F.2d 621, 622 (D.C.Cir.1989). By allowing a qui tam plaintiff to share with the government any proceeds of the action, United States v. Halper, 490 U.S. 435, 109 S.Ct. 1892, 1903 n. 11, 104 L.Ed.2d 487 (1989), the Act provides financial incentives to private parties to expose and prosecute fraud against government. United States v. Burmah Oil Co., 558 F.2d 43, 45 (2d Cir.), cert. denied, 434 U.S. 967, 98 S.Ct. 511, 54 L.Ed.2d 454 (1977). In addition to a share in the proceeds, the FCA Amendments of 1986 now authorize awards of attorney’s fees to prevailing qui tam plaintiffs. 31 U.S.C. § 3730(d)(1) (1988); see S.Rep. No. 345, 99th Cong., 2d Sess. 29, reprinted in 1986 U.S.Code Cong. & Admin.News 5266, 5294. [hereinafter USCCAN],

By allowing certain private parties to sue on behalf of the government, the FCA creates a statutory exception to the general rule regarding standing to sue. United States ex rel. Weinberger v. Equifax, Inc., 557 F.2d 456, 460 (5th Cir.1977), cert. denied, 434 U.S. 1035, 98 S.Ct. 768, 54 L.Ed.2d 782 (1978).

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Bluebook (online)
755 F. Supp. 1040, 1990 U.S. Dist. LEXIS 18719, 1990 WL 255660, Counsel Stack Legal Research, https://law.counselstack.com/opinion/united-states-ex-rel-stinson-lyons-gerlin-bustamante-pa-v-blue-gasd-1990.