Aetna Workers' Comp Access, LLC v. Coliseum Medical Center
322 Ga. App. 641
Ga. Ct. App.2013Background
- AWCA network with Aetna as administrator contracted with Coliseum Medical Center and six other Georgia hospitals to provide care to workers’ comp claimants.
- Payors Builders, Liberty Mutual, and Travelers are insurers; Sedgwick and MediCor act as claims administrators for Payors.
- LOA (Feb 1, 2006) set general services at 98% of Georgia’s workers’ compensation fees and special services at 80%, with Aetna not responsible for payment to Providers and Payors bound to LOA terms.
- Providers allege underpayment for special services (prosthetics, high-cost drugs, implants) totaling over $2.8 million, alleging Aetna directed underpayments and Payors reimbursed at lower rates.
- Providers sue in superior court; Aetna moves to dismiss arguing Board jurisdiction; Payors/Claims Admins also move asserting Board exclusive jurisdiction or lack of contractual privity.
- Trial court denied motions; issues on Board jurisdiction, exculpatory LOA clause, and standing of Payors/Admins as third-party beneficiaries are appealed.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Board vs. superior court jurisdiction over breach claim | Providers argue Board absent ancillary jurisdiction; dispute is contract-based, not employee-rights. | Aetna and Payors argue Board has exclusive jurisdiction over medical fee disputes and related issues. | Board lacks ancillary jurisdiction; breach claims proceed in superior court. |
| Exculpatory clause precluding breach claim against Aetna | Providers assert LOA exculpatory clause does not bar breach claims for failure to administer per LOA terms. | Aetna contends the clause bars any compensation claims against it. | Exculpatory clause is limited to claims for compensation from Payors or breach of LOA; does not bar Providers’ contract claims against Aetna. |
| Payors/Claims Administrators as parties or third-party beneficiaries | Providers allege Payors are contract parties and Providers are third-party beneficiaries of Aetna-Payor contracts. | Payors/Admins contend lack of contractual privity or third-party beneficiary basis, and Board involvement may apply. | Complaint survives as to third-party-beneficiary theory; pled with fair notice, dismissal for failure to state claim not warranted at pleading stage. |
| Board jurisdiction over contract disputes involving fee schedules and underpayments | Providers frame issue as contract-based underpayment rather than a pure fee dispute under Board control. | Board oversees medical fee disputes and related reimbursement rates. | Dispute is contractual between Providers and Payors/Aetna; not solely a medical-fee dispute within Board’s exclusive domain. |
Key Cases Cited
- Builders Ins. Group, Inc. v. Ker-Wil Enterprises, Inc., 274 Ga. App. 522 (2005) (Board jurisdiction limited when employee rights not implicated; contract disputes may proceed in court)
- Austin v. Bank of America, N.A., 293 Ga. 42 (2013) (damages in contract aim to place plaintiff in position had contract been performed)
- Davis, 253 Ga. 376 (1984) (Board retains jurisdiction over Board-approved settlements involving medical expenses)
- Constantine v. MCG Health, Inc., 275 Ga. App. 128 (2005) (exculpatory clause must be explicit; broad ban not present)