Fraud: Health care providers prevail on patient’s ERISA claims

Where a man alleged he was improperly billed by his health care provider, and improperly reimbursed by his health insurer, for blood tests, but some of the claims could not be asserted against the defendants and others failed as a matter of law or fact, the providers were granted summary judgment.

Background

Michael Swartzendruber claims his health care provider (Sentara) and health insurer (United) violated the Employee Retirement Income Security Act of 1974, or ERISA, by overcharging him for hospital services and/or by making misrepresentations about the charges for his blood tests. Before the court are cross motions for summary judgment and plaintiff’s motion to exclude.

Expert

Plaintiff moves to exclude the expert testimony of defendants’ expert, Kristina Kahan. Plaintiff challenges the relevancy and helpfulness of Kahan’s opinions, and disputes that Kahan has offered a sufficient basis on which to offer her opinions.

The court finds that Kahan’s report stands on appropriate bases in that Kahan substantiates her conclusion that the claim was appropriately billed. Though Kahan does not directly explain why the location or service plaintiff received was a hospital location, Kahan has shown that EMHC and SMHC are outpatient centers of a hospital, and that plaintiff received services at EMHC and SMHC. Whether or not Kahan should have discussed the FPA and/or MGPA in making her conclusions goes to the weight of her testimony, not its admissibility.

The court also finds that Kahan presents relevant and helpful evidence as it serves to assist the court in understanding the healthcare claims submission and adjudication processes, including the relevant regulations governing these processes, such that the court is better equipped to address the issues in dispute in this case. Plaintiff’s motion to exclude is thus denied.

United MSJ

United argues that plaintiff is not entitled to any relief on the denial of benefits claim because he cannot prove United abused its discretion in processing his claims. The court agrees. The court finds that United’s decision was reasonable and that United was not willfully blind. It is entitled to summary judgment on this claim.

United moves for summary judgment on Count Two, arguing that United did not act as a fiduciary when it provided cost estimates to plaintiff and that United did not make any material misrepresentations to plaintiff. Because United did not act as a fiduciary when providing estimates or when checking the public credentials of network providers, the court grants summary judgment on Count Two to United. As the court grants summary judgment on this count, the court does not reach plaintiff’s argument that a material issue of fact remains as to whether United committed a material misrepresentation, or United’s argument that plaintiff’s requested equitable relief is not available.

Plaintiff argues that his Count Three is predicated on the denial of benefits claim alleged in his Count One. Therefore, because plaintiff has not established United’s liability under Count One, he is not entitled to relief under Count Three.

Sentra MSJ

Sentara argues it is entitled to summary judgment as to Counts Two and Three, the only counts brought against Sentra, because ERISA does not apply, as Sentara is not a fiduciary. The court cannot discern any basis upon which to impose ERISA liability on Sentara, a non-fiduciary, when the court otherwise found no breach of fiduciary duty by United, an ERISA plan fiduciary.

Therefore, the case before the court at summary judgment does not fall under the exceptions allowing for non-fiduciary liability. As the parties agree Sentara is not a fiduciary, the court cannot find Sentara liable under § 502(a)(3) on these facts. In the alternative, even if a fraudulent misrepresentation claim could lie against the Sentara defendants, plaintiff has not proven a fraudulent misrepresentation occurred, or that Sentara otherwise violated ERISA.

Plaintiff’s motion to exclude expert denied. Plaintiff’s motion for summary judgment denied. Defendants’ motions for summary judgment granted.

Swartzendruber v. Sentara RMH Med. Ctr., Case No. 5:22-cv-55, Sept. 16, 2025. WDVA at Harrisonburg (Urbanski). VLW 025-3-376. 65 pp.