July 15, 2019

July 15, 2019

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District Court Requires Specific Claim and ERISA Plan Allegations In ERISA Complaint

Recently, a federal district court dismissed a hospital’s complaint against an ERISA plan administrator as inadequately pled and outlined the minimum degree of specificity required in similar cases.  In Polk Med. Ctr., Inc. v. Blue Cross & Blue Shield of Ga., Inc., the plaintiff hospital alleged that the defendant administrator was employing various tactics to obstruct and/or reduce reimbursements for emergency treatment, such as refusing to honor assignments of benefits and refusing to pay claims based on supposed past overpayments.  Among its claims, the plaintiff asserted claims for ERISA benefits.

The district court dismissed the hospital’s ERISA claims, finding that the complaint did not provide the plan administrator with “the type of notice that allows it to respond.”  According to the court, “a vague reference to ERISA and non-ERISA plans in general,” with no distinction “between patients who were covered by ERISA plans and . . . by non-ERISA plans” was insufficient.  Such a complaint “provided . . . no notice” as to which ERISA claims were being made, what plans cover the claims, or “how the Defendants have breached the terms of those plans.”

To clarify the pleading standard, the district court noted that successful complaints “provide[d] a specific number of ERISA and non-ERISA claims” and an attached list “providing details of [the] claims.”  The court acknowledged that a plaintiff “may not be required to plead the specific terms of every [ERISA] plan,” but required that the defendant be able to “ascertain” the plan involved.  Both of the successful complaints discussed by the court included exhibits with claim-specific information, such as the date of service or submission.  The district court rejected “judicial economy” as a justification for a lack of specificity.

The district court’s refusal to lower the pleading standard will no doubt encourage future plaintiffs to specify the ERISA plans and claims involved in their complaints.  While requiring more effort initially, the additional information may well improve judicial economy overall by providing more of a basis for settlement discussions and allowing for more targeted discovery.

© Copyright 2019 Squire Patton Boggs (US) LLP


About this Author

Larisa Vaysman, Squire Patton Boggs, appellate litigation

Larisa Vaysman’s practice focuses on general and appellate litigation. She has represented clients before the Sixth, Ninth and DC Circuits, as well as a range of state and federal courts. She has also represented petitioners and amici curiae before the US Supreme Court. Prior to joining Squire Sanders, Larisa clerked for The Honorable R. Guy Cole, Jr. of the United States Court of Appeals for the Sixth Circuit. While in law school, Larisa worked as a summer associate for a Cincinnati law firm.

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