In W.A. Griffin v. Verizon Communications, No. 15-13525 (11th Cir. 2016) (Unpublished), Dr. W.A. Griffin was appealing the dismissal by the district court of her complaint under ERISA. The Eleventh Circuit Court of Appeals (the “Court”) affirmed the district court’s decision.
In this case, Dr. Griffin, who operates a dermatology practice in Atlanta, Georgia, treated two patients insured under a Verizon Communications Inc. (“Verizon”) health plan (the “Plan”). The patients executed assignments that “assign[ed] and convey[ed]” to Dr. Griffin “all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from [Dr. Griffin].” The assignments further stated that they were “valid for all administrative and judicial review under . . . ERISA.” However, the Plan never consented to the assignments. Pursuant to these assignments, Dr. Griffin requested that the Plan pay for the services she rendered to the patients. When the Plan refused to pay the full amount requested, this suit ensued.
In explaining its decision, the Court said that Section 502(a) of ERISA provides that only plan participants and plan beneficiaries may bring a private civil action to recover benefits due under the terms of a plan. A health care provider is not a participant or beneficiary, and thus generally does not have to right to sue the plan under Section 502(a). However, this Court has recognized an exception, under which the health care provider can obtain the right to sue by securing a written assignment from a ‘beneficiary’ or ‘participant’ of his right to payment of benefits under the plan. However, the Plan, in this case, contained an anti-assignment provision, and this Court has enforced such provisions to block the assignment of a claim, so that the health care provider cannot sue. The Court decided to uphold the Plan’s anti-assignment, so that Dr. Griffin cannot sue the Plan.
The Plan’s anti-assignment provision stated: “You cannot assign your right to receive payment to anyone else, except as required by a ‘Qualified Medical Child Support Order’ as defined by ERISA or any applicable state or federal law. . . . The coverage and any benefits under the plan are not assignable by any covered member without the written consent of the plan ….”