This provision creates a federal cause of action for participants and beneficiaries of an employee benefit plan who seek to enforce the terms of their plan. ERISA does not provide an express cause of action for a health care provider seeking payment in excess of that authorized by a plan. Section 1132(a)(1) cannot be interpreted to provide a federal cause of action to vindicate the Hospital's claim for two reasons: first, the Hospital does not have standing to sue under this provision, and second, § 1132(a)(1) does not seek to vindicate the type of claim brought by the Hospital.
Initially, the Hospital is neither a "beneficiary" nor a "participant" in the WLR employee benefit plan. Although there is no governing Third Circuit law on this point, most of the district courts of this Circuit have found either that a health care provider never has standing to sue under 29 U.S.C. § 1132(a)(1), or that it can do so only as an assignee of the rights of the plan participant. See Charter Fairmount Institute, Inc. v. Alta Health Strategies, 835 F. Supp. 233, 1993 WL 410829 (E.D. Pa. 1993) (surveying cases and holding that hospital-assignee has standing to sue under § 1132(a)(1)). In this case, there is no allegation that the Hospital is an assignee of the Kims' rights, nor that the Hospital is suing under the Kims' rights under the plan; instead the Hospital is asserting a claim entirely in its own right under theories of promissory estoppel and misrepresentation.
Furthermore, § 1132(a)(1) only authorizes a suit "to recover benefits due ... under the terms of [the] plan, to enforce ... rights under the terms of the plan, or to clarify ... rights to future benefits under the terms of the plan." The Hospital acknowledges that it is not owed further payment under the terms of the WLR employee health plan, and instead claims a right to be paid under an independent legal relationship that allegedly arose when the Hospital relied on FHP's representations as to the scope of Mrs. Kim's coverage. This claim does not fall within the scope of § 1132(a)(1). Albert Einstein Medical Center v. Action Mfg. Co., 697 F. Supp. 883, 885 n.3 (E.D. Pa. 1988).
WLR argues, however, that the Hospital's allegations of vicarious liability require it to litigate the terms of the WLR employee benefit plan and distinguish this claim from Action Manufacturing and other cases that have held that health care providers' misrepresentation claims are not removable. In its complaint the Hospital alleged that FHP was acting as the agent for the other corporate defendants in answering telephone inquiries and therefore the misrepresentations made by FHP should be imputed to the other corporate defendants. The Hospital argues that a "Payor Agreement" between FHP and WLR
, as well as common law principles of implied agency and apparent authority, establish an agency relationship between the parties independent of the terms of the employee benefit plan, and that its claim is therefore not one to enforce terms of the plan.
WLR agrees that the Payor Agreement is the source of any vicarious liability that might exist among the parties, but argues that because the Payor Agreement establishes a fiduciary relationship between FHP and WLR that is regulated by ERISA, that agreement is essentially part of the employee benefit plan, and any litigation regarding its terms is preempted by ERISA.
This argument is without merit. The statutory definitions of employee benefit plans covered by ERISA do not include fiduciary agreements. See 29 U.S.C. 1002 (1) - (3). Furthermore, § 1132 makes separate provision for suit based on breach of a fiduciary duty in § 1132(a)(2), indicating that such agreements are not subsumed within the enforcement provision for employee benefit plans of § 1132(a)(1).
The terms of the Payor Agreement are independent from the employee benefit plan for the purposes of this litigation. The Hospital's allegations of vicarious liability between the defendants can be litigated without reference to the terms of the employee benefit plan, making this a suit entirely outside the scope of ERISA's enforcement provisions.
2. Is There Affirmative Evidence of Congressional Intent to Permit Removal of Such Claims?
Where the plaintiff's claim falls within the enforcement provisions of § 1132(a), Congress has "clearly manifested" an intent to make such claims removable despite the plaintiff's reliance on state law. Metropolitan Life, 481 U.S. at 65-66. There is no similar evidence that Congress intended to allow removal when the plaintiff's claim does not fall within those enforcement provisions. Allstate, 879 F.2d 90, 94.
Neither of the factors needed to invoke the doctrine of "complete preemption" are present in this case. The case will be remanded to the state court.
AND NOW, this 25th day of January 1994, it is ORDERED that Eugenia Hospital's petition to remand is GRANTED and this matter is REMANDED to the Montgomery County Court of Common Pleas.
Anita B. Brody, J.