Justia U.S. 6th Circuit Court of Appeals Opinion Summaries

Patient, insured by defendant, diagnosed with end-stage renal disease, and received dialysis at plaintiff's center. Three months after diagnosis, she became entitled to Medicare benefits (42 U.S.C. 426-1). Her plan provided that coverage ceased at that time, because of her entitlement to Medicare, but the insurer continued to pay for two months. Under the 1980 Medicare Secondary Payer Act, a group health plan may not take into account that an individual is entitled to Medicare benefits due to end-stage renal disease during the first 30 months (42 U.S.C. 1395y(b)(1)(C)(i)), but the insurer terminated coverage. Plaintiff continued to treat and bill. The insurer declared that termination was retroactive and attempted to offset "overpayment" against amounts due on other patients' accounts. The outstanding balance after patient's death was $210,000. Medicare paid less than would have been received from the insurer. The center brought an ERISA claim, 29 U.S.C. 1132(a)(1)(B), and a claim for double damages under the 1980 Act. The district court granted plaintiff summary judgment on its ERISA claim but dismissed the other. The Sixth Circuit affirmed on the ERISA claim and reversed dismissal. A healthcare provider need not previously "demonstrate" a private insurer's responsibility to pay before bringing a lawsuit under the 1980 Act's private cause of action.

The Medicare program pays teaching hospitals to cover "direct" and "indirect costs of medical education," 42 U.S.C. 1395ww(d)(5)(B), (h). Direct costs include expenses such as residents' salaries. Indirect costs are incurred due to "general inefficiencies" and "extra demands placed on other staff." Congress created a formula for calculating indirect expenses based on full-time equivalency interns; an HHS regulation referred to time residents spend in the "portion of the hospital subject to the prospective payment system or in the outpatient department of the hospital." In reimbursing plaintiff, HHS excluded from the FTE count time residents spent on pure research, unrelated to treatment of a patient. While appeal of a decision favoring the hospital was pending, Congress enacted the Patient Protection and Affordable Care Act, 124 Stat. 119, 660–61. For the years at issue, HHS must include in FTE: "all the time spent by an intern or resident in an approved medical residency training program in non-patient care activities, such as didactic conferences and seminars, as such time and activities are defined by the Secretary." HHS promulgated a regulation specifying that eligible non-patient care activities do not include time residents spend conducting pure research. The Sixth Circuit upheld the regulation as within the Secretary's authority and applicable to the years at issue.

The district court certified a class action and a proposed class in an action under the Employee Retirement Income Security Act, 29 U.S.C. 1001. The suit claimed that Blue Cross breached its fiduciary duty by imposing and failing to disclose an other-than-group subsidy and that the OTG subsidy violated Mich. Comp. Laws 550.1211(2). The state insurance commissioner took the position that state law allows the assessment and that revenue it generates funds Medigap coverage. The Sixth Circuit reversed, holding that the class action is not the superior method of adjudication (Federal Rule of Civil Procedure 23(b)(3)) and prosecuting separate actions does not present the risk of inconsistent adjudications (FRCP 23(b)(1)(A)). ERISA fiduciary status is a crucial threshold factual issue specific to every class member, requiring the court to make individualized determinations. Resolution of the legality of the subsidy before that determination would also mitigate the state's concerns about stopping collection of the fee. Potential awards at stake would not preclude individual class members from seeking relief and there was no evidence that individual litigation would create a risk of inconsistent adjudications that would establish incompatible standards of conduct for the defendant.

Plaintiff, employed by a company contracted to do grounds maintenance, was injured while mowing grass at an Army base. A deteriorating steam pipe fell, striking him in the head. The district court granted summary judgment to the United States, reasoning that under the Kentucky Workers' Compensation Law, the United States was an up-the-ladder contractor, or statutory employer, so that plaintiff's only remedy was the workers' compensation benefits he received from his direct employer. The Sixth Circuit affirmed, holding that the U.S. government is a "person" entitled to the up-the-ladder defense and that the waiver of immunity under the Federal Torts Claims Act, 28 U.S.C. 1346, provides for claims in the same manner and to the same extent as a private individual. The government "secured the payment of compensation" by hiring a contractor and, therefore, cannot be treated as an employer that did not secure benefits. The work performed by plaintiff was a "regular and recurrent" part of work at the facility and the government was entitled to contractor immunity.

The trust was created by the Chapter 11 bankruptcy plan of a corporation that, from 1965 to 1981, manufactured and sold automotive products containing asbestos. Numerous suits were filed concerning those products. Coverage through one primary insurer has been exhausted; two primary insurers are defending. The trust holds an umbrella insurance policy issued by defendant, which contends that it is not required to defend the claims. The district court agreed and dismissed the trust's complaint. The Sixth Circuit affirmed. Although the umbrella policy schedule of primary carriers only lists the policy that has been exhausted, the umbrella policy applies, by its unambiguous terms, the umbrella policy applies only where an occurrence is not covered by the underlying insurance listed in the schedule, "or any other underlying insurance collectible by the insured."

The first plaintiffs alleged that Fidelity failed to provide a discount, required by its filed rates, when issuing title insurance to homeowners who had purchased a title insurance policy for the same property from any other insurer within the previous 10 years. The second plaintiff brought the same claims against First American. The district court denied their motion to certify a class. The Sixth Circuit affirmed. Although the claims involve small amounts, so that the plaintiffs are likely unable to recover except by class action, the plaintiffs did not establish that issues subject to generalized proof and applicable to the whole class predominate over issues subject to individualized proof. The need to establish entitlement to join the class and the need to prove individual damages are not fatal to class certification, but the Ohio insurance rate structure would necessitate individual inquiries on the issue of liability. The plaintiffs phrased their claims in a way that would require examination of individual policies and whether the company received the requisite documentation for the discount.

A podiatrist, primarily serving elderly patients, was convicted of healthcare fraud counts that resulted in a loss of $120. The podiatrist was sentenced to 18 months in prison followed by three years of supervision and ordered to pay more than $244,000, based on acquittal counts. The Sixth Circuit affirmed the conviction, but vacated and remanded the sentence. There was sufficient evidence that the podiatrist mailed bills for patients who were not actually treated and for work done by staff no longer employed at the office. Sentencing based on acquittal counts is not unconstitutional if those counts have been established by a preponderance of evidence, but the sentence was unreasonable. Although a court need only make a reasonable estimate of loss, the court relied solely on statistical evidence about loss from up-coding without a sound representative sample. The acquittal counts were part of a broad scheme to defraud and an award of restitution, based on those counts, was proper.