American Journal of Law & Medicine

ERISA: insurer not entitled to discounted fees--HCA Health Serv. Georgia, Inc. v. Employers Health Insur. Co.

The Eleventh Circuit held that an insurer was not entitled to a discounted fee based on a series of contracts allegedly extending such benefit from the provider to the insurer.(2) The Appellam, a health care provider, brought an action on behalf of a patient under the Employee Retirement Income Security Act of 1974 ("ERISA")(3) challenging the discount claimed by Employers Health, Inc. ("EHI") for services provided to the patient. It was determined that the group health insurance policy purchased from EHI by the patient was an employee benefit plan within the meaning of ERISA, since it related to medical benefits.(4) EHI appealed from a gram of summary judgment in the district court. The district court held that the provider was not barred from bringing a derivative standing suit based upon an assignment of rights from "a participant or beneficiary of an employee benefit plan" listed within 29 U.S.C. [sections] 1132(a).(5) On appeal, EHI claimed that appellant failed to exhaust all administrative resources prior to bringing the ERISA suit. The court held that the evidence of communications between the parties indicated that the provider participated with the insurance company in the appeals process after the claim was implicitly denied.(6)

The patient, Steven Denton ("Denton"), was a member of an employee welfare benefit plan provided by EHI. Denton had surgery performed by Parkway Medical Center ("Parkway"), an EHI out-of-network provider. …

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