On Thursday, the court issued an order in a case brought by Classic Air Care against Aetna Life Insurance Company et al. The opinion, issued in the District of Utah, dealt with Classic’s claim that Aetna had waived a non-assignment clause in the patients contract by processing Classic’s claim as in-network and denied the motion to dismiss from the defendant, Aetna.
In 2018, Classic provided air ambulance service for a patient who had insurance coverage through an employer plan under ERISA. During the transfer, the patient signed an assignment of benefits to Classic for processing and payment of the claim in the amount of $89,725. Aetna processed the claim as an in network claim and paid only $8,834.81. Classic disputed this payment as there is no contract between Classic and Aetna and followed procedures for appealing and disputing the payment method, finally initiating a full suit with claims under 29 U.S.C. § 1132(a)(1)(B) and 29 U.S.C. § 1133 for recovery of benefits, and under 29 U.S.C. § 1132(a), §§ 1104–05, and § 1109 as well as three state law claims. Aetna filed a 12(b)(6) motion to dismiss all claims, stating that Classic had no standing to pursue the payment due to an anti-assignment clause in the patients contract and stating that the claims should be dismissed for failure to state a claim.
The court noted that the patient was enrolled in an ERISA plan that had a valid and unambiguous anti-assignment clause that would ordinarily prevent an insurance company from filing a claim on their own behalf or from receiving the benefits from the plan directly. The court held that despite the anti-assignment clause, Aetna had never raised this issue and to the contrary had treated Classic as a direct assignee in processing the claim and in dealing with the processing of the appeals and denials of the claim, which the court held gave rise to unequivocal act on the part of Aetna to waive the anti-assignment clause and giving Classic the right to pursue the claim directly. The court also noted that Classic had made a novel argument that anti-assignment clauses are against public policy as they result in unfair denials of claims involved with emergency services, but noted that there was no caselaw supporting this proposition and was moot in light of the waiver of the anti-assignment clause from Aetna. The recovery of benefits claim under 29 U.S.C. § 1132(a)(1)(B) was allowed, while the remaining claims were dismissed as superseded by the 29 U.S.C. § 1132(a)(1)(B) claim.