United States District Court, D. Maryland
MEMORANDUM AND ORDER
K. Bredar, United States District Judge.
before the Court is Plaintiff’s motion for limited
discovery (ECF No. 19), which has been briefed (ECF Nos. 23
and 33). Also pending is Defendant’s motion for leave
to file surreply (ECF No. 37), to which Plaintiff has
responded (ECF No. 40). No hearing is necessary. Local Rule
105.6 (D. Md. 2014). The motions will be denied.
filed in the District Court of Maryland for Cecil County,
this case was removed to this Court because the claim is
acknowledged by the parties as arising under certain
provisions of the Employee Retirement Income Security Act
(“ERISA”), 29 U.S.C. §§ 1331 and 1367.
(Am. Compl., ECF No. 32; Notice of Removal, ECF No. 1.)
Plaintiff, Upper Bay Surgery Center, LLC (“Upper
Bay”), is a health care service provider who has sued
Defendant Aetna Health and Life Insurance Company
(“Aetna”) for underpayment of a claim made on
behalf of an individual who received services from Upper Bay
on May 5, 2015. (Am. Compl. ¶ 15.)
Bay submitted a charge of $9, 701.00, Aetna set an allowable
charge of $2, 408.88, and Aetna paid Upper Bay $2, 288.44.
(Id. ¶16.) Upper Bay contends it was entitled
to receive ninety percent of the Prevailing Charge Rate for
the geographic area; the Prevailing Charge Rate is derived
from rates reported by the FAIR Health database.
(Id. ¶¶ 19, 22.) Instead, Aetna paid Upper
Bay in an amount that corresponded to 200% of the Medicare
reimbursement rate for ambulatory surgical centers.
(Id. ¶ 22.) Upper Bay contends Aetna’s
reimbursement breached the terms of the patient’s
health insurance plan. (Id. ¶ 28.) Upper Bay
seeks what it alleges is the proper reimbursement amount,
costs, and fees, as well as a declaration and an injunction,
applicable to the patient at issue and all future patients
with Aetna-administered health insurance, that Aetna must
reimburse in accordance with Upper Bay’s interpretation
of the plan; Upper Bay also seeks a statutory penalty for
Aetna’s alleged failure to provide Upper Bay with the
documents on which Aetna’s reimbursement decision was
based. (Id. ¶¶ 29, 32, 37-39.)
has generally denied Upper Bay’s allegations of
impropriety in setting the reimbursement amount and has
asserted various defenses to bar any recovery. (Ans., ECF No.
35.) Following Upper Bay’s receipt from Aetna of the
administrative record, Upper Bay filed the instant motion for
limited discovery (ECF No. 19), which is now ripe for
ERISA case that involves a request for judicial review of the
denial of insurance benefits, such review is ordinarily
confined to the administrative record, and extrinsic
discovery is only permitted in exceptional circumstances.
Quesinberry v. Life Ins. Co. of No. Am., 987 F.2d
1017, 1026-27 (4th Cir. 1993). See also Perlman v. Swiss
Bank Corp. Comprehensive Disability Prot. Plan, 195 F.3d
975, 981-82 (7th Cir. 1999), cited in Donnell v. Metro.
Life Ins. Co., 165 F. App’x 288, 297 (4th Cir.
2006) (unpublished). Upper Bay has failed to establish
exceptional circumstances justifying extrinsic discovery
Bay contends that, at the present time, it only seeks the
discovery of one number-the Prevailing Charge Rate in effect
at the time of service rendered to the patient. However,
Upper Bay indicates that if Aetna argues it has discretion to
interpret the patient’s benefit plan or that the
assignment being relied upon by Upper Bay is unenforceable,
then it will require additional discovery. In the latter
instance, Upper Bay wants discovery
in regard to Aetna’s regular dealings with Upper Bay
over a period of years, whether Aetna has ever asserted that
Upper Bay’s assignments were invalid, and how Aetna
regularly addresses its anti-assignment provisions.
Generally, Upper Bay would request Aetna to produce any
correspondence from Aetna to Upper Bay making reference to
anti-assignment provisions in the Aetna Benefit Plan which
covered any patient with Aetna health insurance that received
care at Upper Bay for a period of three years before May 5,
2015. Upper bay would also request Aetna to produce any
correspondence from Aetna to any out-of-network health care
provider making reference to anti-assignment provisions in
the Aetna Benefit Plans which covered any patients that
received care at those facilities for a period of three years
before May 5, 2015. Finally, Upper Bay would request Aetna to
produce any internal, nonprivileged, communications regarding
anti-assignment provisions, including employee training
materials, sample documents, and templates, created or used
in a period of three years before May 5, 2015.
(Pl.’s Mot. 5, ECF No. 19.)
former instance, pertaining to discretion to interpret the
benefit plan, Upper Bay says it “will need discovery in
regard to eight non-exclusive factors identified in Booth
v. Wal-Mart Stores, Inc., 201 F.3d 335, 342-43 (4th Cir.
2000).” (Pl.’s Mot. 5-6.) Third, “if Aetna
claims that its 200% payment was appropriate, Upper Bay will
need discovery in regard to any such claim, and Aetna’s
justification for that claim.” (Id. 6.)
language of the plan documents obviates any claimed need for
discovery by Upper Bay. Under the plan, a claimed covered
expense is only that part of a charge which is the recognized
medical, vision and hearing expenses, the recognized charge
for each service or supply is the lesser of:
• What the provider bills or submits for that service or
• For professional services and other services or
supplies not ...