Griffin v. Teamcare

Dr. Griffin provided medical care to T.R., a participant in a Central States health plan. Before receiving treatment, T.R. assigned to Griffin the rights to “pursue claims for benefits, statutory penalties, [and] breach of fiduciary duty ….” Griffin confirmed through a Central representative that the plan would pay for the treatment at the usual, reasonable, and customary rate, then treated T.R. and submitted a claim for $7,963. Griffin later challenged the benefits determination, requesting a copy of the summary plan description and documents used to determine her payment. Six months later, Central responded that iSight, a third party, used “pricing methodology” to determine the fee and telling her to negotiate with iSight before engaging in the appeals process that the plan required before a civil suit. Griffin missed a call from iSight, returned the call, and left a message that she “would not take any reductions.” iSight never called back. Central provided a copy of the summary plan description, but no fee schedules or tables. Griffin sued under ERISA, 29 U.S.C. 1132(a)(1)(B), (a)(3), alleging that Central did not pay her the proper rate under the plan; breached its fiduciary duty by not adhering to plan terms; and failed to produce, within 30 days, the summary plan description she requested, nor iSight’s fee schedules. The court dismissed. The Seventh Circuit affirmed in part and vacated in part. Griffin adequately alleged that she is eligible for additional benefits and statutory damages. View "Griffin v. Teamcare" on Justia Law