Wise v. United Healthcare of Fla., Inc.

387 F. Supp. 3d 1382
CourtDistrict Court, M.D. Florida
DecidedMay 1, 2019
DocketCase No. 8:19-cv-00455-T-02JSS
StatusPublished
Cited by2 cases

This text of 387 F. Supp. 3d 1382 (Wise v. United Healthcare of Fla., Inc.) is published on Counsel Stack Legal Research, covering District Court, M.D. Florida primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Wise v. United Healthcare of Fla., Inc., 387 F. Supp. 3d 1382 (M.D. Fla. 2019).

Opinion

WILLIAM F. JUNG, UNITED STATES DISTRICT JUDGE

This action concerns a contractual dispute over insurance coverage. The matter comes to the Court on Plaintiff's motion to remand the case to Florida state court. Dkt. 5. Defendant has filed an opposition to the motion. Dkt. 12. The Court GRANTS the motion.

BACKGROUND

According to the Complaint filed in the Circuit Court of the Thirteenth Judicial *1385Circuit in and for Hillsborough County, Florida, Plaintiff's parents have an insurance policy through Defendant as a supplement to their Medicare plans. Dkt. 1-2 at 6. The Evidence of Coverage, which includes the terms of the policy, provides for services related to home health agency care. Id. at 6-7. As long as relevant conditions are met, an insured must pay a $0 copayment for in-network services and 50% coinsurance for out-of-network services. Id. at 7. That out-of-network service provider must be "eligible to participate in Medicare." Id. at 8. This is in contrast to other provisions in the Evidence of Coverage that require providers to be "certified" by Medicare. Id.

Though Plaintiff's parents satisfy the conditions for coverage, Defendant has not identified in-network home health agencies that could provide listed services. Id. at 9-10. Plaintiff's parents eventually received services through DS In Home Services, Inc. as an out-of-network provider that is "eligible to participate in Medicare." Id. at 10. Plaintiff submitted to Defendant medical reimbursement request forms for the cost of services. Id.

Defendant denied payment because the services were a "Medicare non covered service" and "[t]he provider is not listed as a certified CMS provider." Id. at 10-11. After extensive communication between the parties, Defendant informed Plaintiff there were no in-network or out-of-network providers that were "eligible to participate in Medicare" that could provide services. Id. at 11. Though Defendant has partially reimbursed some of the services Plaintiff's parents received, Defendant has "failed and refused to provide the Insureds with complete, consistent, and continuous coverage and/or reimbursement for the Home Health Aide Services." Id. at 12.

Plaintiff seeks a declaratory judgment declaring Defendant's obligations under his parents' insurance policy, namely relating to the distinction between "eligible" or "certified" service providers and Defendant's failure to identify available providers of home health care services. Id. at 13-14. Defendant removed the case to the United States District Court for the Middle District of Florida on February 21, 2019, arguing jurisdiction lies under 28 U.S.C. § 1442(a)(1) and § 1331. Dkt. 1.

DISCUSSION

The Court has neither federal officer removal jurisdiction nor federal question jurisdiction. Remand is therefore appropriate.

I. Federal Officer Removal Jurisdiction

Section 1442(a)(1) allows for removal of civil actions against:

The United States or any agency thereof or any officer (or any person acting under that officer) of the United States or of any agency thereof, in an official or individual capacity, for or relating to any act under color of such office or on account of any right, title or authority claimed under any Act of Congress for the apprehension or punishment of criminals or the collection of the revenue.

28 U.S.C. § 1442(a)(1). Though the phrasing varies by case, a private party seeking to remove under the federal officer removal statute must: (i) be a "person"; (ii) be "acting under" a federal officer or agency; (iii) be sued for or relating to actions "under color of such office"; and (iv) have a colorable federal defense. See Brokaw v. Nat'l Air Cargo Holdings, Inc. , No. 6:15CV1658-O-37KRS, 2015 WL 8265590, at *2 (M.D. Fla. Dec. 9, 2015) (citation omitted); see also Caver v. Cent. Ala. Elec. Coop. , 845 F.3d 1135, 1142 (11th Cir. 2017) (finding that a plaintiff must show "a causal connection between what the officer has *1386done under asserted official authority and the action against him").1 Defendant argues that, by providing coverage through a Medicare Advantage plan ("MA plan"), it is "acting under" the direction of the U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services ("CMS"). The Court disagrees.

As an initial matter, the Medicare Act creates a federally subsidized health insurance program administered through CMS. See Barrows v. Burwell , 777 F.3d 106, 108 (2d Cir. 2015). Medicare Parts A and B provide for inpatient and outpatient services, respectively. Id. Part C allows for beneficiaries to opt out of coverage under A and B and into MA plans offered by private companies called Medicare Advantage Organizations ("MAOs"). Premier Inpatient Partners LLC v. Aetna Health & Life Ins. Co. , 362 F. Supp. 3d 1217, 1219 (M.D. Fla. 2019) (citations omitted). MAOs contract with patients for rates and costs of medical services, while CMS pays the MAO a fixed fee per enrollee. Id. (citation omitted); see also Humana Med. Plan, Inc. v. W. Heritage Ins. Co. , 832 F.3d 1229, 1235 (11th Cir. 2016) (explaining in detail Medicare Part C).

To be sure, MA plans are regulated and, to some extent, monitored by CMS. Mann v. Reeder , No. 1:10-CV-00133-JHM, 2010 WL 5341934, at *3 (W.D. Ky. Dec. 21, 2010) ; see also

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Bluebook (online)
387 F. Supp. 3d 1382, Counsel Stack Legal Research, https://law.counselstack.com/opinion/wise-v-united-healthcare-of-fla-inc-flmd-2019.