ERISA PREEMPTION OF STATE LAW CLAIM | MEDICAL BENEFITS COVERAGE, PARTIAL DENIAL OF CLAIM |
SUIT BY PROVIDER FOR MEDICAL SERVICES | SUMMARY JUDGMENT BASED ON LIMITATIONS IN THE
Ambulatory Infusion Therapy Specialists, Inc.
v. North American Administrators, Inc.
(Tex.App.- Houston [1st Dist.] Juy 10, 2008)(Keyes) (health care coverage, claim denial, ERISA preemption,
breach of contract, promissory estoppel, summary judgment based on limitations, accrual of cause of action)
HOLDING: The reviewing court holds that AITS’s state law claims are preempted by
ERISA and that the trial court properly granted summary judgment on those claims. The
trial court properly determined that appellant’s common law claims were preempted by
ERISA. The court of appeals would alternatively affirm the summary judgment on the
basis of limitations.
AFFIRM TC JUDGMENT: Opinion by Justice Evelyn Keyes
Before Justices Taft, Keyes and Alcala
01-06-00756-CV Ambulatory Infusion Therapy Specialists, Inc. v. North American Administrators, Inc. d/b/a North
American Health Plans and Osmose, Inc.
Appeal from 125th District Court of Harris County
Trial Court Judge: Hon. John Coselli
O P I N I O N
Appellant, Ambulatory Infusion Therapy Specialist, Inc. (“AITS”), appeals the trial court’s order granting summary
judgment in favor of appellees, North American Administrators, Inc. d/b/a North American Health Plans (“NAHP”)
and Osmose, Inc. In six issues on appeal, AITS argues that (1) the trial court erred in sustaining NAHP’s
objections to AITS’s summary judgment evidence; (2) the trial court erred in finding that not more than a scintilla
of evidence supported AITS’s claim for breach of contract; (3) the trial court erred in finding that not more than a
scintilla of evidence supported AITS’s claim for promissory estoppel; (4) the trial court erred in finding that
appellees established as a matter of law that AITS’s state law claim for breach of contract was preempted by
ERISA; (5) the trial court erred in finding that appellees established as a matter of law that AITS’s state law claim
for promissory estoppel was preempted by ERISA; and (6) the trial court erred in granting appellees’ motion for
summary judgment on limitations because appellees failed to establish as a matter of law that the statute began
running prior to December of 2001.
C.R., an employee of Osmose, had insurance through Osmose’s employee healthcare plan (“Osmose Plan”). In
April 2001, C.R. needed home IV therapy medical services. Before providing medical services to C.R., AITS, an
out-of-network medical provider, alleged that it called NAHP, the third-party claims administrator for Osmose, to
verify that the medical services provided would be covered. An agent for NAHP told AITS that the medical
services would be reimbursed. AITS then provided the medical services and sought reimbursement of $31,089.20
from NAHP on April 2, 2001. On June 26, 2001, in an “Explanation of Benefits” letter to AITS, NAHP agreed to
reimburse $3,500 of AITS’s claim, but denied the remaining $22,689.20 because it was above the usual and
customary charges for the services rendered to C.R. Footnote On August 28, 2001, AITS appealed NAHP’s
decision to deny the claim by letter to NAHP. By letter dated December 12, 2001, NAHP denied the appeal after
determining that it had correctly paid the claim.
On October 14, 2005, AITS sued NAHP and Osmose to recover $27,589.20 Footnote based on the medical
services it had provided to C.R. AITS brought claims for breach of contract, negligent misrepresentation, and
promissory estoppel. NAHP Footnote sought a traditional and no-evidence summary judgment based on the
statute of limitations and on its contention that AITS’s claims were preempted by the Employment Retirement
Income Security Act of 1974 (“ERISA”). Footnote Osmose also filed a traditional motion for summary judgment.
At the summary judgment hearing, in response to the statute of limitations argument, AITS argued that it was
“relying on an implicit oral agreement between plaintiff and North American Administrators pursuant to [AITS’s
president Connie Hudec’s] conversation with Debbie,” an NAHP representative, made in Hudec’s telephone call to
NAHP to verify coverage, in which Debbie allegedly represented that AITS’s charges for services rendered to C.
R. would be covered. Counsel for AITS stated that “our breach of contract claim is based on the oral agreement
between [NAHP] as agent for Osmose and Ms. Hudec” and that “[w]e are not bringing a breach of contract case
under an assignee of the plan. We have not stepped into the shoes of the patient in this case.” After the hearing,
the trial court granted summary judgment, agreeing with the appellees that the statute of limitations had run and
that AITS’s claims were preempted by ERISA. AITS appeals from the trial court’s order.
In its fourth and fifth issues, AITS contends that the trial court erred in finding that NAHP established as a matter
of law that AITS’s state law claims for breach of contract and promissory estoppel were preempted by ERISA and
that it, therefore, can go forward with its claims.
NAHP and Osmose argued in their summary judgment motions that all of AITS’s claims were preempted by ERISA
because AITS’s claims sought benefits under an ERISA Footnote employee plan, the Osmose Plan. AITS
It is irrelevant to this case whether C.R. was covered under the Plan for the supplies and services provided by
AITS, and AITS neither seeks benefits from the Plan nor claims that the Plan acted improperly in processing and
denying AITS’s claim. AITS’s claims are thus independent of the Plan’s actual obligations under the terms of the
insurance policy, and AITS in no way seeks to modify those obligations. Rather, AITS, as a third-party healthcare
provider, seeks damages from an insurance company and its alleged agents, claiming that, had it not been for
the promise to pay for supplies and services to be provided to C.R., AITS would not have accepted the financial
risk of providing said supplies and services to C.R.
It is well established that the legal treatment of claims under Texas law focuses on the true nature of disputes
rather than allowing artful pleading to gain favorable redress under the law. See Baylor Univ. v. Sonnichsen, 221
S.W.3d 632, 636 (Tex. 2007) (forbidding morphing contract claims into fraud causes of action). A plaintiff cannot
simply recast a claim in order to avoid having its cause of action statutorily barred. Viviano v. Moore, 899 S.W.2d
326, 327 (Tex. App.—Houston [14th Dist.] 1995, pet. denied); see also In re Merrill Lynch Trust Co. FSB, 235 S.
W.3d 185, 188 (Tex. 2007) (applying same rule to arbitration); Garland Cmt’y Hosp. v. Rose, 156 S.W.3d 541,
543–44 (Tex. 2004) (forbidding use of artful pleading to avoid Health Care Liability Act’s requirements when
essence of suit is health care liability claim). Thus, we focus on the true nature of the dispute between AITS and
NAHP to determine whether or not AITS’s claims are a disguised attempt to expand the terms of a benefit plan
covered by ERISA and are, therefore, preempted.
Congress enacted ERISA as a comprehensive system to regulate employee benefit plans “to promote the
interests of employees and their beneficiaries in employee benefit plans . . . [and] to protect contractually defined
benefits.” Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 113, 109 S. Ct. 948, 956 (1989). The act
regulates both pension plans and welfare plans that provide benefits for contingencies such as illness, accident,
disability, death, or unemployment. Cathey v. Metro. Life Ins. Co., 805 S.W.2d 387, 388 (Tex. 1991). While it
provides standards and rules governing reporting, disclosure, and fiduciary responsibility for pension and welfare
plans, ERISA does not mandate any particular benefits. Shaw v. Delta Air Lines, Inc., 463 U.S. 85, 91, 103 S. Ct.
2890, 2896–97 (1983).
ERISA includes expansive preemption provisions, which are intended to ensure that employee benefit plan
regulation be “exclusively a federal concern.” Alessi v. Raybestos-Manhattan, Inc., 451 U.S. 504, 523, 101 S. Ct.
1895, 1906 (1981). To this end, Congress has statutorily provided that ERISA “shall supersede any and all state
laws insofar as they may now or hereafter relate to any employee benefit plan.” Employee Retirement Income
Security Act of 1974, 29 U.S.C. § 1144(a) (2006). ERISA preemption applies not only to state laws but to all forms
of state action dealing with the subject matters covered by the statute. 29 U.S.C. § 1144(c)(1); see also Shaw,
463 U.S. at 98, 103 S. Ct. at 2900. Accordingly, when a state court suit, alleged in terms of a state common-law or
statutory cause of action, relates to an employee welfare benefit plan, ERISA may preempt the state law in favor
of federal law. Metro. Life Ins. Co. v. Taylor, 481 U.S. 58, 63–67, 107 S. Ct. 1542, 1546–48 (1987); Gorman v.
Life Ins. Co. of N. Am., 811 S.W.2d 542, 545 (Tex. 1991).
The ERISA preemption provision is to be broadly construed. See Aetna Health Inc. v. Davila, 542 U.S. 200, 216–
17, 124 S. Ct. 2488, 2500 (2004) (stating that Court’s understanding of ERISA’s preemptive effect is informed by
“overpowering federal policy” embodied in ERISA’s civil enforcement provision, which was intended to create “an
exclusive federal remedy”). However, the Supreme Court has cautioned that “[s]ome state actions may affect
employee benefit plans in too tenuous, remote, or peripheral a manner to warrant a finding that the law ‘relates
to’ the plan.” Shaw, 463 U.S. at 100 n.21, 103 S. Ct. at 2901 n.21. To determine whether a state law claim has the
forbidden connection to ERISA, we look to both the objectives of ERISA and the effect of the asserted state law
on ERISA plans. Egelhoff v. Egelhoff, 532 U.S. 141, 147, 121 S. Ct. 1322, 1327 (2001). Because the scheme is
deemed to be comprehensive with regard to the remedies provided and excluded, any state law cause of action
that duplicates, supplements, or supplants the ERISA civil enforcement remedy conflicts with the Congressional
intent to make the ERISA remedy exclusive and is preempted. See Davila, 542 U.S. at 209, 124 S. Ct. at 2495.
The Fifth Circuit Court of Appeals has propounded a two-pronged test whereby ERISA preempts a state law claim
if “(1) the state law claim addresses an area of exclusive federal concern, such as the right to receive benefits
under the terms of an ERISA plan; and (2) the claim directly affects the relationship between the traditional ERISA
entities-the employer [in its role as administrator], the plan and its fiduciaries, and the participants and
beneficiaries.” Hubbard v. Blue Cross & Blue Shield Ass’n, 42 F.3d 942, 945 (5th Cir. 1995); see also Mayeaux v.
La. Health Serv. & Indem. Co., 376 F.3d 420, 432 (5th Cir. 2004).
ERISA also contains express jurisdictional provisions. Section 502(a)(1)(B) and (e) of ERISA, codified at Title 29
section 1132(a)(1)(B) of the United States Code, provides for a civil action by a beneficiary (1) “to recover
benefits due to him under the terms of a plan”; (2) to enforce his rights under the plan; or (3) to clarify his rights
to future benefits under the plan. 29 U.S.C. § 1132(a). Subsection (e) of section 1132 provides that the federal
courts have exclusive jurisdiction over ERISA claims, except that state courts of competent jurisdiction and district
courts of the United States have concurrent jurisdiction of actions by a beneficiary or plan participant within the
scope of section 1132(a)(1)(B), stating, “Except for actions under subsection (a)(1)(B) of this section, the district
courts of the United States shall have exclusive jurisdiction of civil actions under this title brought by the Secretary
or by a participant.” 29 U.S.C. § 1132(e)(1). Thus, for actions by an ERISA plan participant “to recover benefits
due [to him] under the terms of his plan,” the state and federal courts have concurrent jurisdiction. See Gorman,
811 S.W.2d at 546; Haynes v. Haynes, 178 S.W.3d 350, 353 (Tex. App.—Houston [14th Dist.] 2005, pet. denied).
Even though state courts have jurisdiction over claims under ERISA section 1132(a)(1)(B) to recover benefits due
under the terms of an ERISA plan, state law claims seeking relief within the scope of section 1132(a)(1)(B) are
completely preempted by ERISA. See Mayeaux, 375 F.3d at 432; Hubbard, 42 F.3d at 945. Moreover, in such
instances of complete preemption, a state law claim may be re-characterized as an action to recover benefits
under ERISA, and the state courts will have jurisdiction over that claim, although the claim may be subject to
removal to federal court as a claim “arising under” federal law. Arana v. Ochsner Health Plan, 338 F.3d 433, 439–
40 (5th Cir. 2003); see 28 U.S.C. §§ 1331 and 1441(a) (providing for removal). If, however, a claim relates to an
employee benefit plan governed by ERISA but is not a claim for benefits due under the policy or a suit to enforce
or clarify rights under the policy, and therefore within the scope of section 1132(a)(1)(B), it will fall within the
exclusive jurisdiction of the federal courts under ERISA. See 29 U.S.C. § 1132(e)(1). Accordingly, if a state law
claim relates to an ERISA plan but does not fall within the scope of section 1132(a)(1)(B) and (e)(1), an assertion
of ERISA preemption is, if successful, jurisdictional. Saks v. Franklin Covey Co., 316 F.3d 337, 349–50 (2d Cir.
By contrast, if a claim falls within the scope of section 1132(a)(1)(B) and (e)(1), it will be preempted, but the
preemption will ordinarily not be jurisdictional, because the state and federal courts have concurrent jurisdiction
over such actions. See Mills v. Warner Lambert Co., 157 S.W.3d 424, 425 (Tex. 2005) (ordinarily preemption
operates as affirmative defense to plaintiffs’ state-law claims but does not deprive state courts of jurisdiction over
those claims; state-court jurisdiction is affected only when Congress requires that claims be addressed
exclusively in federal forum). Nevertheless, if a plaintiff’s state law claims are preempted by ERISA section 1132(a)
(1)(B), and no claim is asserted under ERISA, summary judgment dismissing those claims is appropriate. See
Mayeaux, 376 F.3d 420, 430, 433; Cadillac Ins. Co. v. L.P.C. Distrib. Co., 770 S.W.2d 892, 894–95 (Tex. App.—
San Antonio 1989, writ denied) (when employer and employees did not attempt to assert cause of action under
ERISA for insurer’s allegedly wrongful cancellation of insurance contract and failed to make sufficient allegations
to confer jurisdiction over state law claims under ERISA’s “savings clause” for state law insurance, banking, and
insurance claims, 29 U.S.C. §1144(b)(2)(A), subject matter jurisdiction was not conferred on state court).
Finally, despite ERISA preemption’s expansive scope, if a state law claim does not seek to recover or replace
benefits under an employee welfare benefit plan and is based on a violation of a legal duty independent of
ERISA, it is not preempted by ERISA and may go forward as a state law claim. Haynes, 178 S.W.3d at 354; see
also Davila, 542 U.S. at 210, 124 S. Ct. at 2496. Necessarily, state law claims based on the violation of a legal
duty independent of ERISA do not “relate to” ERISA so as to implicate preemption or federal jurisdiction. In such a
case, absent diversity, and with no other basis for “arising under” jurisdiction, it is the federal court that is
deprived of subject matter jurisdiction to hear the cause. See, e.g., Peacock v. Thomas, 516 U.S. 349, 352–54,
116 S. Ct. 862, 865–66 (1996) (holding veil-piercing claim does not state cause of action under ERISA and
cannot independently support federal subject matter jurisdiction); Hook v. Morrison Milling Co., 38 F.3d 776, 785–
86 (5th Cir. 1994) (affirming remand of common law negligence suit after finding claim did not relate to and
therefore was not preempted by ERISA). Accordingly, since AITS contends its claims are based on an
independent state law duty of NAHP and are not preempted, while NAHP contends AITS’s claims are disguised
claims to recover benefits due a participant under an ERISA plan and are, therefore, within the scope of ERISA
section 1132(a)(1)(B) and are preempted, we must determine what, if any, preemptive effect ERISA has in the
instant case and the resulting effect on subject matter jurisdiction.
The Parties’ Contentions
On appeal, AITS argues that it is not seeking benefits under the Osmose Plan, but rather it is seeking damages in
regard to an independent promise made by an agent of NAHP to pay for medical services given to C.R., and
therefore its state law claims are not preempted by ERISA. AITS argues that “had it not been for the promise to
pay for supplies and services to be provided to C.R., AITS would not have accepted the financial risk of providing
said supplies and services to C.R.” AITS places great emphasis on the fact that it is not seeking to recover
benefits as an assignee of the patient. Footnote NAHP responds that “Appellant’s action to recover benefits from
a covered plan falls directly within the civil enforcement provision of ERISA, which provides an exclusive federal
cause of action for the resolution of such disputes.” NAHP thus relies on the preemptive effect of section 502(a)(1)
(B) of ERISA, 29 U.S.C. § 1132(a)(1)(B).
The arguments that AITS advances against ERISA’s preemption of its claims are not novel. AITS itself has
advanced identical arguments on essentially identical facts in a federal forum to an adverse conclusion. See
Ambulatory Infusion Therapy Specialists, Inc. v. Aetna Life Ins. Co., H-05-4389, 2007 WL 320974 (S.D. Tex. Jan.
30, 2007). Footnote The federal district court set out the facts and procedural history of AITS’s prior case as
Ambulatory Infusion Therapy Specialists, Inc. (“AITS”), an at-home infusion treatment provider, sued Aetna Life
Insurance Company and Prudential Insurance Company of America in Texas state court, alleging a right to
recover the amounts billed for medical services provided to a patient. The patient, N.D., worked for The Kroger
Company, which funded an employee health insurance plan (the “Plan”). Prudential provided third-party claims
administrative services to the Plan until 1999, when Aetna began providing those services.
Beginning in late 2000, AITS provided medical services to N.D. and submitted claims to Aetna for payment for
those services under the Plan. Aetna paid most of the amounts invoiced but denied payment on approximately
15% to 20% of the submitted charges on the grounds that they were duplicative or exceeded the reasonable and
customary fees for the services.
AITS sued Aetna and Prudential in Texas state court, asserting state-law claims for breach of contract, negligent
misrepresentation, and promissory estoppel. (Docket Entry No. 9, Ex. 1, ¶¶ V-VII). The defendants removed on
the grounds that ERISA completely preempted AITS’s claims and that this court had diversity jurisdiction. This
court denied AITS’s motion to remand by Memorandum and Order issued in June 2006, finding that the breach of
contract claim was completely preempted. This court ordered AITS to replead if it intended to assert an ERISA
claim. AITS did replead but asserted no ERISA claim. Instead, AITS reasserted the same state-law breach of
contract, negligent misrepresentation, and promissory estoppel causes of action. (Docket Entry No. 15). Aetna
and Prudential filed a motion to dismiss on the basis that ERISA preemption barred all AITS’s state-law claims.
(Docket Entry No. 18). AITS responded, arguing that none of its claims were preempted. (Docket Entry No. 19).
AITS also moved for leave to file a second amended complaint to add a state-law fraudulent misrepresentation
claim. (Docket Entry No. 20).
In its Memorandum and Order of August 29, 2006, this court denied AITS’s motion for leave to amend to add the
fraud claim, dismissed the breach of contract claim on the basis of complete ERISA preemption, converted the
defendants’ motion to dismiss the remaining negligent misrepresentation and promissory estoppel claims into one
for summary judgment, and set a schedule for discovery tailored to resolving the summary judgment motion. The
parties have completed that discovery.
Aetna and Prudential have moved for summary judgment on AITS’s negligent misrepresentation and promissory
Id. at *1; see also AITS v. Aetna Life Ins. Co., No. H-05-4389, 2006 WL 2521411 (S.D. Tex. June 13, 2006); AITS
v. Aetna Life Ins. Co., No. H-05-4389, 2006 WL 1663752 (S.D. Tex. June 13, 2006).
In the prior federal case, as here, AITS’s president, Hudec, testified that she called the patient’s insurance
company, Prudential Plus, to verify coverage before administering services to the patient, N.D., and spoke to
“Nancy.” 2007 WL 320974, at *3. This telephone call was the only conversation between AITS and either
Prudential or Aetna regarding the patient’s plan coverage. Id. at *4. “Based on her telephone call with Nancy on
October 9, 2000, Hudec believed that AITS would be paid for the services it provided to N.D. under the Plan.
Hudec testified that Nancy said that N.D. had out-of-network coverage under the Plan, which Hudec took to mean
that ‘my claims would be paid.’” Id. (citations to record omitted). AITS claimed that it was not asserting its claims as
the patient’s assignee. Id. at *8. Rather, it argued, as here, that it was “seeking to recover damages for services
that it would not have provided ‘had it not been for the communications made by Defendants’ agents to pay for
supplies and services to be provided to N.D’” during the telephone call by Hudec to verify coverage. Id.
The only perceivable differences between the facts in this case and the facts in the federal case are that, in the
prior case, the ERISA plan and the defendants are different and, in the prior case, AITS did receive an
assignment of the plan benefits provided to the patient, see 2006 WL 1663752, although it insisted it was not
asserting its state law claims as the patient’s assignee, see 2007 WL 320974, whereas, here, AITS did not get an
assignment of benefits from the participant or the beneficiary, C.R. Footnote However, we do not find that these
distinctions save AITS from the same fate it suffered in federal court. AITS admits that if it did have an assignment
of benefits from C.R., its claims would be preempted. To allow AITS to maintain its state law claims only on the
basis that it did not have an assignment of benefits “would allow parties who lacked standing to sue under ERISA
to circumvent its provisions by filing suit in state courts under state law, thereby obtaining advantages denied to
parties enumerated under ERISA Section 502(a).” Hermann Hosp. v. MEBA Med. & Benefits Plan, 959 F.2d 569,
576, 578 (5th Cir. 1992) (holding that “ERISA preempted Hermann’s state law claims irrespective of whether
Hermann brought those claims as an enumerated party under ERISA Section 502(a) or in another capacity”). We
thus disagree with AITS’s argument that it is not seeking benefits because it did not get an assignment of benefits
from C.R. Its failure to obtain an assignment of the benefits on which its claim against C.R.’s employer, Osmose,
and the Osmose Plan’s insurer is premised does not preclude ERISA preemption.
AITS does not contend that the Osmose Plan is not an ERISA plan, nor does it contend that C.R. had no
coverage under that Plan. Instead, it contends that it had a separate and independent contract with NAHP
whereby NAHP agreed to pay 100% of any services AITS provided to C.R., a covered employee under the
Osmose Plan. The federal courts, including the federal district court in AITS’s prior suit against Aetna and
Prudential, have drawn a distinction between cases in which the existence of coverage is in dispute, which are not
preempted, and those in which the dispute is merely over the extent of coverage, which are preempted. See
Hermann Hosp. v. The Cent. States, Se. & Sw. Areas Health and Welfare Fund, 962 F. Supp. 993, 997 (S.D. Tex.
1997); AITS, 2007 WL 320974, at *7–8.
In a situation in which the patient has no coverage at all, a third-party service provider’s misrepresentation claim
against an ERISA plan cannot “relate to” the plan because the patient, and therefore the service provider, has no
connection to the plan beyond the alleged misrepresentation. See Cent. States, 962 F. Supp. at 997; AITS, 2007
WL 320974, at *7. Thus, “the proper inquiry is whether the beneficiary under the ERISA plan was covered at all
by the terms of the health care policy, because if the beneficiary was not, the provider of health services acts as
an independent, third party subject to the holding in Memorial [Hosp. Sys. v. Northbrook Life Ins. Co.]” that such a
third party’s independent claims are not preempted. AITS, 2007 WL 320974, at *8; see Memorial, 904 F.2d 236,
243–46 (5th Cir. 1990); see also Transitional Hosp. Corp. v. Blue Cross & Blue Shield of Tex., Inc., 164 F.3d 952,
954 (5th Cir. 1999) (“ERISA does not preempt state law when the state-law claim is brought by an independent,
third-party health care provider (such as a hospital) against an insurer for its negligent misrepresentation
regarding the existence of health care coverage.”). When the patient has at least some coverage, however, the
connection with the ERISA plan is present, and to allow the hospital to pursue its state law claims would permit the
hospital to expand the limited rights granted to the plan beneficiary and thereby defeat the purposes of ERISA
altogether. Cent. States, 962 F. Supp. at 997.
AITS’s claim, although couched in terms of an attempt to recover on an independent promise to pay for medical
benefits based on breach of contract and promissory estoppel, is really an attempt to expand the rights of the
patient, C.R., under the Osmose Plan to 100% of services rendered by a third-party service provider, in defiance
of the terms of coverage and of established law. In the words of the federal court in AITS’s suit against Aetna and
Prudential, the claim “simply challenges the decision that certain amounts billed were not covered by the Plan
terms.” AITS, 2007 WL 320974, at *10. The dispute is, thus, not about the existence of coverage, but about the
extent of coverage. See Cent. States, 962 F. Supp. at 997. Therefore, although AITS did not get an assignment
of benefits from C.R., its “claim is derivative of [C.R.’s] rights under the Plan and dependent on the Plan terms.”
AITS, 2007 WL 320974, at *10. As such, to resolve AITS’s claim for breach of contract and promissory estoppel
would require an inquiry into the Osmose Plan administration, an area of exclusive federal concern. See id.
We agree with the federal district court in AITS’s prior suit against Aetna that AITS’s state law claims fall within the
purview of Mayeaux and are preempted. See Mayeaux, 376 F.3d at 432–33; AITS, 2007 WL 320974, at *10. Both
the AITS court and the Mayeaux court held that the plaintiff’s state law claims were “in substance a collateral
challenge to the ERISA insurer/administrator’s coverage determination” and thus ERISA conflict preemption
applied. AITS, 2007 WL 320974, at *10; see Mayeaux, 376 F.3d at 432–33.
Specifically, in Mayeaux, the Fifth Circuit agreed with the district court that the third-party provider’s state law
claims against the insurer for negligence, unfair trade practices, defamation, and intentional interference with
contracts related to an ERISA plan because they challenged the insurer’s “handling, review, and disposition of a
request for coverage” and thus collaterally attacked the insurer’s determination of the actual obligation under the
terms of the insurance policy. 376 F.3d at 432–33. It concluded that if a third party “could collaterally challenge a
plan’s decision not to provide benefits, he would directly affect the relationship between the plan and its
beneficiary, two traditional ERISA entities. That clearly cannot be allowed,” and thus the state law claims could not
survive ERISA conflict preemption. Id. at 433. The court had “no difficulty holding that ‘the existence of an [ERISA]
plan [was] a critical factor in establishing liability’ for the state law causes of action asserted by [the plaintiff].” Id.;
see also Ingersoll-Rand Co. v. McClendon, 498 U.S. 133, 139–40, 111 S. Ct. 478, 483 (1990). Like the federal
district court in AITS’s prior case, the federal court of appeals in Mayeaux affirmed the district court’s grant of
summary judgment to the defendant on the plaintiff’s ERISA and state law claims. Mayeaux, 376 F.3d at 433. We
agree with both courts and do likewise.
We overrule AITS’s fourth and fifth issues. We hold that AITS’s state law claims are preempted by ERISA and that
the trial court properly granted summary judgment on those claims. Even if we had not concluded, however, that
the trial court properly held that appellant’s common law claims were pre-empted by ERISA, we would still have
affirmed the summary judgment on limitations.
In its sixth issue on appeal, AITS argues that the trial court erred in granting summary judgment on its common
law contract and promissory estoppel claims based on statute of limitations.
A defendant moving for summary judgment on the affirmative defense of limitations must conclusively prove when
the cause of action accrued. KPMG Peat Marwick v. Harrison County Hous. Fin. Corp., 988 S.W.2d 746, 748
(Tex. 1999). The statute of limitations for a breach-of-contract cause of action is four years. Tex. Civ. Prac. &
Rem. Code Ann. § 16.004(a)(3) (Vernon 2002). Likewise, the statute of limitations for promissory estoppel is four
years. Id. § 16.051 (Vernon 1997); Farah v. Mafrige & Kormanik, P.C., 927 S.W.2d 663, 680 (Tex. App.—Houston
[1st Dist.] 1996, no writ). A breach of contract claim accrues when the contract is breached. Stine v. Stewart, 80 S.
W.3d 586, 592 (Tex. 2002). The contract is not breached until a wrongful act occurs. See Anderson v. Cocheu,
176 S.W.3d 685, 690 (Tex. App.—Dallas 2005, pet. denied). “A cause of action generally accrues, and the
statute of limitations begins to run, when facts come into existence that authorize a claimant to seek a judicial
remedy.” Johnson & Higgins of Tex., Inc. v. Kenneco Energy, Inc., 962 S.W.2d 507, 514 (Tex. 1998). In most
cases, a cause of action accrues when a wrongful act causes a legal injury, regardless of when the plaintiff learns
of that injury or if all resulting damages have yet to occur. S.V. v. R.V., 933 S.W.2d 1, 4 (Tex. 1996).
Here, the June 26, 2001 explanation of benefits letter showed that NAHP was paying only $3,500 of AITS’s
$31,089.20 invoice, thus denying reimbursement for $27,589.20. Upon receipt of the June 26, 2001 letter, AITS
had knowledge of an injury—the denial of benefits in the amount of $27,589.20—and, therefore, had sufficient
facts to seek a judicial remedy. Footnote See Pace v. Travelers Lloyds of Tex. Ins. Co., 162 S.W.3d 632, 634–35
(Tex. App.—Houston [14th Dist.] 2005, mand. motion denied); Thompson v. Great Am. Life Ins. Co., 2005 WL
1072706, at *3 (W.D. Tex. May 5, 2005) (holding that “the fact that Defendant would ‘reconsider’ its decision
indicates to a reasonable recipient that a decision to deny coverage had already been made and communicated
to Plaintiff. Thus . . . Plaintiff possessed sufficient information to allow him to go to court to seek a judicial remedy,
and his cause of action accrued on that date.”). Although AITS did not know the full extent of its injury, it
nonetheless knew that an injury—denial of benefits—had occurred. See S.V., 933 S.W.2d at 4 (stating “a cause
of action accrues when a wrongful act causes some legal injury, even if the fact of injury is not discovered until
later, and even if all resulting damages have not yet occurred”). We thus conclude that the statute of limitations
commenced on June 26, 2001, the date in which AITS learned that NAHP denied payment. AITS did not timely file
suit within the statute of limitations, and, therefore, its state law claims, if not preempted, would be time-barred.
We affirm the judgment of the trial court. Footnote
Evelyn V. Keyes
Panel consists of Justices Taft, Keyes, and Alcala.