Judge Allyne Ross
Medical laboratory Enigma alleged United Healthcare’s failure to fully pay claims for services provided to United health insurance plan participants. United claimed Enigma did not collect required deductible and coinsurance payments. Enigma sought $1.225 million, alleging contract breach, unjust enrichment and fraudulent misrepresentation. Asserting preemption by ERISA, United removed suit to district court. Applying Aetna Health Ins. v. Davila, the court deemed Enigma’s claims preempted by ERISA and denied remand to state court. The action implicated Enigma’s right to payment and fell within the scope of ERISA’s civil enforcement scheme. Further, the court will need to interpret United’s summary plan description (Plan) to decide if United could require credit card or bank statements as proof of the deductible’s or coinsurance payment. Thus Enigma’s unjust enrichment claim implicated the “right to payment.” Such a claim can be brought under ERISA. The alleged fraudulent misrepresentation related to ERISA as the Plan governed the issues of whether Enigma had to collect payments from participants in order to receive full payment on its claims,and as to what types of documentation were accepted as proof of payment.
