The Fourth Circuit issued an opinion in a lawsuit Tuesday, which was originally filed by Sandra Peters against Aetna Inc.; Aetna Life Insurance Company; and OptumHealth Care Solutions, Inc. The appellate panel affirmed in part, reversed in part, vacated in part, and remanded a Western District of North Carolina decision back to the district court after finding errors in their evaluation.
According to the opinion, Mars, Inc. “operated a self-funded health care plan (the Plan) and hired Aetna as a claims administrator of the Plan pursuant to a Master Services Agreement.” Aetna executed several subcontracts with Optum so that they could “provide chiropractic and physical therapy services to the Plan participants for more cost-effective prices than Aetna alone could provide.”
In June 2015, Sandra Peters filed a class action lawsuit against Aetna, alleging violations of the Employee Retirement Income Security Act (ERISA). The plaintiff claimed she was overbilled for healthcare; however, she “did not take into account the cumulative impact of her annual deductible and coinsurance payments, as well as the effect of her other non-Optum medical services.” The district court denied class certification, concluding that neither company could be held liable under the ERISA.
Using the framework of a similar case, the Fourth Circuit upheld the district court’s grant of summary judgment to Aetna, declaring that the plaintiffs do not deserve restitution. The court noted that Peters wanted to focus solely on specific healthcare charges within the bundle, which is actually more expensive than the bundle as a whole. The court found that Peters paid less on her new healthcare plan than on her old one. However, the court vacated the district court’s summary judgment to Aetna in part because they needed to “develop a fuller record of the relevant financial facts … and determine the Plan’s financial injury for restitution purposes.” The court also reversed summary judgment given for Aetna’s fiduciary status, after determining that the district court made an error in their analysis.
Continuing, Peters and the class were granted surcharge and disgorgement since Aetna “was unjustly enriched when avoiding payment of Optum’s administrative fee and causing Peters and the Plan to shoulder that expense.” Furthermore, the court reversed the district court’s summary judgment to Optum “in so far as that it could not be held liable as a party in interest under ERISA.” Finally, the court vacated and remanded the district court’s order denying class certification.