W. A. Griffin, MD v. Delta Air Lines, Inc.

Eleventh Circuit

W. A. Griffin, MD v. Delta Air Lines, Inc.

CourtCourt of Appeals for the Eleventh Circuit

DecidedFebruary 24, 2021

Docket18-10418

StatusPublished

This text of W. A. Griffin, MD v. Delta Air Lines, Inc. (W. A. Griffin, MD v. Delta Air Lines, Inc.) is published on Counsel Stack Legal Research, covering Court of Appeals for the Eleventh Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook

W. A. Griffin, MD v. Delta Air Lines, Inc., (11th Cir. 2021).

Pincite

Opinion

USCA11 Case: 18-10418 Date Filed: 02/24/2021 Page: 1 of 26

[PUBLISH]

IN THE UNITED STATES COURT OF APPEALS

FOR THE ELEVENTH CIRCUIT ________________________

No. 18-10417 ________________________

D.C. Docket No. 1:17-cv-04656-AT

W. A. GRIFFIN, MD,

Plaintiff - Appellant,

versus

COCA-COLA REFRESHMENTS USA, INC., UNITED HEALTHCARE INSURANCE COMPANY,

Defendants - Appellees,

UNITED HEALTHCARE OF GEORGIA, INC.,

Defendant.

________________________

No. 18-10418 ________________________

D.C. Docket No. 1:17-cv-04657-AT

W. A. GRIFFIN, MD, USCA11 Case: 18-10418 Date Filed: 02/24/2021 Page: 2 of 26

DELTA AIR LINES, INC., UNITED HEALTHCARE INSURANCE COMPANY,

UNITED HEALTHCARE PLAN OF GEORGIA, INC.,

Appeals from the United States District Court for the Northern District of Georgia ________________________

(February 24, 2021)

Before BRANCH and MARCUS, Circuit Judges, and UNGARO,∗ District Judge.

BRANCH, Circuit Judge:

Dr. Wakitha Griffin, a dermatologist in Atlanta, Georgia, has filed many

appeals in this Court in recent years, all of which have involved her attempts to

receive in-network payments despite being an out-of-network provider. Our other

opinions have been unpublished; we choose to publish today in hopes of resolving

this recurring litigation.

∗ The Honorable Ursula Ungaro, United States District Court for the Southern District of Florida, sitting by designation.

2 USCA11 Case: 18-10418 Date Filed: 02/24/2021 Page: 3 of 26

These consolidated appeals arise from Griffin’s treatment of two patients

who were insured under two separate employee welfare benefit plans which are

administered by United Healthcare (“United”). The Employee Retirement Income

Security Act of 1974 (“ERISA”) covers both plans. Because Griffin does not have

a contract with United whereby she provides services in exchange for

reimbursement at a negotiated rate, she is an out-of-network provider under both

plans. Generally, patients are reimbursed at lower rates when receiving healthcare

services from out-of-network providers rather than in-network providers.

Eschewing a contractual relationship with United and payment from her

patients, Griffin instead requested that the two patients assign their benefits under

their plans to her. They obliged. Griffin then attempted to collect from United the

same payment that she would have received had she been an in-network provider.

When United only paid her the benefits she was entitled to as an out-of-network

provider, Griffin brought two separate lawsuits—one against Coca-Cola

Refreshments, Inc. (“Coca-Cola”) and United and the other against Delta Air

Lines, Inc. (“Delta”) and United (collectively, “Defendants”)—asserting various

ERISA violations. The district court dismissed both cases for failure to state a

claim because the plans’ anti-assignment clauses prevented Griffin from obtaining

statutory standing under ERISA to sue on behalf of her patients. Griffin appealed

both cases to this Court.

3 USCA11 Case: 18-10418 Date Filed: 02/24/2021 Page: 4 of 26

These consolidated appeals raise an unsettled issue about whether an ERISA

plan administrator or its claims agent may waive its right to rely on an anti-

assignment provision in an ERISA-covered plan. We need not reach that issue,

however. Even assuming that waiver is available in the ERISA context,

Defendants did not waive their ability to assert the anti-assignment provisions as a

defense. And regardless of waiver, Griffin’s lawsuit still fails to state a claim:

United paid her in full, both under the terms of the patients’ assignments and the

provisions of the healthcare plans. We therefore affirm the district court’s orders.

I. Background

Although these consolidated appeals implicate two distinct health benefit

plans, patients, and assignments, the facts giving rise to Griffin’s claims in each

case are largely the same. A few years ago, Griffin provided medical treatment for

two patients: Patient J.J., who was insured under the Coca-Cola Plan, and Patient

G.A., who was insured under the Delta Plan. 1 United is the Coca-Cola Plan’s

Claims Fiduciary and the Delta Plan’s Claims Administrator. Under the terms of

both plans, Griffin is an “out of network” physician. Generally, the plans

reimburse the beneficiary at a higher percentage when he visits an in-network

physician rather than an out-of-network physician. For example, the Coca-Cola

1 The Coca-Cola Company Benefits Committee is the Coca-Cola Plan Administrator and the Administrative Committee of Delta Air Line, Inc. is the Delta Plan Administrator. 4 USCA11 Case: 18-10418 Date Filed: 02/24/2021 Page: 5 of 26

Plan provides that when a beneficiary has an office visit with an out-of-network

physician, the plan pays 60 percent of the cost of service and the beneficiary pays

40 percent. By contrast, if the beneficiary has an office visit with an in-network

physician, the plan pays at least 80 percent.

In exchange for medical treatment and in lieu of payment, the two patients

executed an assignment of their plan benefits to Griffin. Both assignments are

identical. By signing, the patient acknowledges that the document is “a direct legal

assignment of my rights and benefits under this policy and designation of

authorized representative” and “authorize[s] any plan administrator or fiduciary,

insurer, and my attorney to release to such provider(s) any and all plan

documents.” The assignment further provides that the patient has assigned “all

medical benefits and/or insurance reimbursement, if any, otherwise payable to [the

patient] for services rendered from such provider(s), regardless of such provider’s

managed care network participation status.”

Griffin believed that the assignments entitled her to full payment for her

services, as if she were an in-network provider. She submitted claims to United,

which she alleges United only partially paid. Griffin appealed United’s payment

determinations. In her appeals, Griffin made numerous requests, including: (1)

that United disclose the plan’s unambiguous anti-assignment provision, should the

5 USCA11 Case: 18-10418 Date Filed: 02/24/2021 Page: 6 of 26

plan have one; (2) copies of the plan documents; and (3) the identification of the

Plan Administrator.

United denied each appeal and responded directly to the patients, copying

Griffin on the communications. In each appeal denial, United explained that

Griffin was not reimbursed the full amount of her charges because of the relevant

plan’s provisions regarding out-of-network coverage and deductibles. United

therefore upheld the payment determinations and did not address Griffin’s specific

requests. Undeterred, Griffin submitted second level appeals for both claims and

reiterated her requests. United again denied the appeals without addressing

Griffin’s requests.

After exhausting her administrative remedies, Griffin, proceeding pro se,

filed two complaints in Georgia state court: one against United and Coca-Cola, for

her treatment of Patient J.J., and the other against United and Delta, for her

treatment of Patient G.A. The operative complaints are nearly identical and bring

the same four claims: failure to pay plan benefits under 29 U.S.C.

Free access — add to your briefcase to read the full text and ask questions with AI