March 18, 2010 REVISED June 29, 2010

New Porter Review here

United States District Court, E.D. Kentucky, Northern Division, Ashland.

"In addition, Plaintiffs' claim sounds in ERISA. Absent ERISA, there would be no obligation between the parties. Of note in this regard is United States Supreme Court decision in which participants in an ERISA plan sued the plan administrators in tort, alleging injury arising from the administrators' decisions to deny coverage for certain treatments. Aetna Health, Inc. v. Davilla, 542 U.S. 200 (2004). The Supreme Court rejected the Plaintiffs' argument that the action sounded in state tort law, finding that liability only exited because of the ERISA plans that bound the parties. Id.

As in Davilla, that Porter and his practice have a provider contract with Anthem does not, in and of itself, create an independent legal duty for Anthem to make payments to Porter. What is payable, and, more importantly, what is not is defined by the terms of the benefit plans and, thus, governed by ERISA." 
A PPO participating provider sued the Anthem for alleged wrongful overpayment recoupment in the state court. "Defendant argues that this case could have been brought under ERISA and is thus subject to federal jurisdiction. The Court agrees."
The court mainly relied upon the U.S. Supreme Court unanimous landmark decision in Aetna v. Davila, and ruled that PPO overpayment recoupment dispute is 100% ERISA business, not PPO business at all.

For more notes on this case, click here.