ER Addison LLC v. Aetna Health Inc
3:24-cv-01816
N.D. Tex.Jul 3, 2025Background
- Plaintiffs, a group of freestanding emergency centers (collectively, “ER”), provided emergency healthcare services to individuals insured by Aetna but allege Aetna underpaid them.
- ER operates as out-of-network providers and relies on payments from insurers like Aetna for revenue, as they cannot offset lower reimbursements with hospital admissions or other ancillary services.
- ER filed suit against Aetna in July 2024, asserting a federal claim under ERISA and state-law claims for breach of contract, negligent misrepresentation, and unjust enrichment.
- Aetna moved to dismiss under Rule 12(b)(1) (lack of subject matter jurisdiction), Rule 12(b)(2) (lack of personal jurisdiction), and Rule 12(b)(6) (failure to state a claim).
- At issue was whether ER had standing to assert ERISA claims on behalf of Aetna’s insureds, based on alleged assignments of benefits, and whether ERISA plan anti-assignment provisions barred such standing.
- The court resolved the motion without oral argument, considering both pleadings and additional evidence presented.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether ER has standing to sue under ERISA via assignment | ER received assignments of benefits from patients | ER lacks evidence of assignments; plans contain anti-assignment provisions | ER failed to prove valid assignments; no standing |
| Effect of anti-assignment provisions on standing | Aetna is estopped from enforcing, or provisions are invalid under TX law | Anti-assignment clauses are valid and enforceable; ERISA preempts TX law | Provisions are enforceable; ERISA preempts TX statute |
| Whether court should exercise supplemental jurisdiction | (Implicit) Court may retain state claims | Dismiss all claims if federal dismissed | Declined supplemental jurisdiction; dismissed state claims |
| Standard for 12(b)(1) factual attack consideration | Only pleadings should be considered | Evidence outside pleadings should be considered | Court considers and weighs evidence outside the pleadings |
Key Cases Cited
- Harris Methodist Fort Worth v. Sales Support Servs., 426 F.3d 330 (5th Cir. 2005) (healthcare provider may obtain derivative standing under ERISA via patient assignments)
- N. Cypress Med. Ctr. Operating Co. v. Cigna Healthcare, 781 F.3d 182 (5th Cir. 2015) (provider must show assignment of benefits and patient standing)
- Mello v. Sara Lee Corp., 431 F.3d 440 (5th Cir. 2005) (establishing elements for ERISA estoppel claim)
- Dialysis Newco, Inc. v. Cmty. Health Sys. Grp. Health Plan, 938 F.3d 246 (5th Cir. 2019) (anti-assignment provisions in ERISA plans are valid and enforceable)