642 F.3d 321 (2d Cir. 2011)
Ramification of Court Decision:
- It is 100% ERISA, even for in-network providers.
- In-Network Provider Has Standing to Pursue ERISA Remedies, But State Law Reimbursement Claim Completely Preempted by ERISA
- In Montefiore Medical Center v. Teamsters Local 272, 642 F.3d 321 (2d Cir. 2011), the U.S. Court of Appeals for the Second Circuit held that an in-network provider’s state law based reimbursement claim is completely preempted by the Employee Retirement Income Security Act of 1974, 29 U.S.C. §1001, et seq. (ERISA), and rejected the provider’s argument that an otherwise valid assignment of benefits is a “nullity” whenever care is provided in-network.
- Significantly, the Second Circuit found that Montefiore’s actual claims could be classified as claims for benefits because they involve the “right to payment,” as distinguished from the “amount of payment,” and therefore, implicate coverage decisions under the plan, such as pre-certification requirements, covered services under the plan and membership eligibility.