Pa. Chiropractic Ass'n v. Independence Hosp. Indem., Inc., No. 15-1274 (7th Cir. 2015)
Annotate this CaseThe insurer operates a preferred-provider system that offers patients better benefits, or lower co-payments, for patronizing medical providers who have agreed with the insurer to accept lower reimbursements (per procedure) in exchange for a better flow of business. The chiropractor plaintiffs signed such “participating provider” or “network” agreements. Providers bill the insurer directly regardless of whether a patient obtained coverage as part of an Employee Retirement Income Security Act (ERISA) welfare-benefit plan or through some other means, such as an affinity-group policy or an insurance exchange under the Affordable Care Act. Chiropractors sued, contending that, when determining how much to pay for services rendered to patients, the insurer failed to use the procedures required by ERISA, 29 U.S.C. 1133. The district court concluded that plaintiffs are beneficiaries under ERISA and awarded damages and injunctions requiring the insurer to follow section 1133 and Department of Labor regulations. The Seventh Circuit reversed, noting that plaintiffs concede that they are not participants under the ERISA definition and that a network contract between a medical provider and an insurer does not make that provider a “beneficiary” under ERISA.
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