Case 4:21-cv-02477 Document 1 Filed on 07/30/21 in TXSD Page 1 of 6
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`UNITED STATES DISTRICT COURT
`FOR THE SOUTHERN DISTRICT OF TEXAS
`HOUSTON DIVISION
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`TRUSTMARK HEALTH BENEFITS, INC.,
`
`
`
`v.
`
`ST. LUKE’S HEALTH SYSTEM
`CORPORATION d/b/a
`ST. LUKE’S THE WOODLANDS
`HOSPITAL.,
`
`
`
`Plaintiff,
`
`Defendant.
`
`
`
`
`Case No. 4:21-cv-2477
`
`
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`PLAINTIFF’S ORIGINAL COMPLAINT
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`
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`Plaintiff Trustmark Health Benefits, Inc. f/k/a CoreSource, Inc. (“Trustmark”) files this
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`Original Complaint against Defendant St. Luke’s Health System Corporation d/b/a St. Luke’s The
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`Woodlands Hospital (“St. Luke’s”), and respectfully states as follows:
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`I. PARTIES
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`1.
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`Plaintiff. Trustmark is a Delaware corporation with its principal place of business
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`in Lake Forest, Illinois, and does business in Texas.
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`2.
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`St. Luke’s Health System Corporation d/b/a St. Luke’s The Woodlands Hospital
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`(“St. Luke’s”). St. Luke’s is a Texas corporation with its principal place of business in Houston,
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`Texas, which may be served with process by serving its registered agent, C T Corporation System,
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`at 1999 Bryan St., Ste. 900, Dallas, TX 75201-3136.
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`II. VENUE AND JURISDICTION
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`3.
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`The Court has jurisdiction over the lawsuit under 28 U.S.C. § 1331, as this action
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`arises under 29 U.S.C. § 1132(a)(3). Venue is proper pursuant to 28 U.S.C. § 1931 (b)(2), as a
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`substantial part of the events giving rise to this action took place in this district.
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`PLAINTIFF’S ORIGINAL COMPLAINT
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` PAGE 1
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`UNITED STATES DISTRICT COURT
`FOR THE SOUTHERN DISTRICT OF TEXAS
`HOUSTON DIVISION
`
`TRUSTMARK HEALTH BENEFITS, INC.,
`
`
`
`v.
`
`ST. LUKE’S HEALTH SYSTEM
`CORPORATION d/b/a
`ST. LUKE’S THE WOODLANDS
`HOSPITAL.,
`
`
`
`Plaintiff,
`
`Defendant.
`
`
`
`
`Case No. 4:21-cv-2477
`
`
`
`§
`§
`§
`§
`§
`§
`§
`§
`§
`§
`§
`
`
`
`PLAINTIFF’S ORIGINAL COMPLAINT
`
`
`
`
`
`
`Plaintiff Trustmark Health Benefits, Inc. f/k/a CoreSource, Inc. (“Trustmark”) files this
`
`Original Complaint against Defendant St. Luke’s Health System Corporation d/b/a St. Luke’s The
`
`Woodlands Hospital (“St. Luke’s”), and respectfully states as follows:
`
`I. PARTIES
`
`1.
`
`Plaintiff. Trustmark is a Delaware corporation with its principal place of business
`
`in Lake Forest, Illinois, and does business in Texas.
`
`2.
`
`St. Luke’s Health System Corporation d/b/a St. Luke’s The Woodlands Hospital
`
`(“St. Luke’s”). St. Luke’s is a Texas corporation with its principal place of business in Houston,
`
`Texas, which may be served with process by serving its registered agent, C T Corporation System,
`
`at 1999 Bryan St., Ste. 900, Dallas, TX 75201-3136.
`
`II. VENUE AND JURISDICTION
`
`3.
`
`The Court has jurisdiction over the lawsuit under 28 U.S.C. § 1331, as this action
`
`arises under 29 U.S.C. § 1132(a)(3). Venue is proper pursuant to 28 U.S.C. § 1931 (b)(2), as a
`
`substantial part of the events giving rise to this action took place in this district.
`
`
`PLAINTIFF’S ORIGINAL COMPLAINT
`
`
`
` PAGE 1
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`Case 4:21-cv-02477 Document 1 Filed on 07/30/21 in TXSD Page 2 of 6
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`III. BACKGROUND FACTS
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`A. The Primeway Federal Credit Union Employee Health Care Plan
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`4.
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`Trustmark is the third-party claims processor for the Primeway Federal Credit
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`Union Employee Health Care Plan (the “Plan”), which is a self-funded employee benefit plan
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`governed by the Employee Retirement Income Security Act of 1974 (“ERISA”). The Plan was
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`adopted and implemented by Primeway Federal Credit Union, which is the Plan Sponsor and Plan
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`Fiduciary. Primeway Federal Credit Union contracted with Trustmark to provide third-party
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`claims processing and administration services to the Plan.
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`5.
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`Accordingly, Trustmark adjudicates the group benefit claims under the terms of the
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`Plan and has authority to pursue recovery of this overpayment on behalf of the Plan.
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`6.
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`From January 27, 2020 through January 28, 2020, a participant (the “Patient”) of
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`the Plan received medical services at St. Luke’s The Woodlands Hospital (“St. Luke’s”). St.
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`Luke’s is a non-preferred provider of the Plan. As such, St. Luke’s billed charges are not pre-
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`negotiated with, or agreed to by, the Plan or Trustmark. Nonetheless, claims submitted by St.
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`Luke’s under the Plan are subject to the terms thereof. Shortly after rendering medical services to
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`the Patient, St. Luke’s submitted a claim on the Patient’s behalf under an assignment of benefits
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`from the Patient, ultimately seeking benefits under the Plan.
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`7.
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`8.
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`The billed charges for the Patient’s claim totaled to $34,917.49.
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`On or around April 22, 2020, Trustmark timely processed the claim on behalf of
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`the Plan, but it inadvertently calculated a net payment of $30,919.63, which represented full billed
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`charges, less the Patient’s deductible of $540.00 and coinsurance of $3,457.86.
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`9.
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`Importantly, however, the terms of the Plan set forth the Permitted Payment Levels
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`provision for inpatient services:
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`PLAINTIFF’S ORIGINAL COMPLAINT
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` PAGE 2
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`Case 4:21-cv-02477 Document 1 Filed on 07/30/21 in TXSD Page 3 of 6
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`Inpatient Services. The permitted payment level for covered expenses shall
`be calculated at the average of 150% of the Medicare allowable amount for
`the covered expense and 135% of the cost of the covered expense; provided,
`however, that any such permitted payment level based on the cost of the
`covered expense shall be limited to an amount not to exceed 175% of the
`Medicare allowable amount or the amount of usual, customary and
`reasonable fees for the covered expense.
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`10.
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`After a subsequent audit of this claim, the overpayment was discovered. Indeed, the
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`Plan’s claim delegate, Advanced Medical Pricing Solutions, determined that the Medicare
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`allowable amount of the claim was $8,984.24, and the cost based allowable amount was $7,447.90.
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`These amounts average to be $8,216.07, which did not exceed the ceiling of 175% of the Medicare
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`allowable amount, and thus should have been the correct allowable amount for this claim.
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`11.
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`Taking into account the appropriate Patient responsibility amount results in an
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`overpayment of $24,346.73, which is due back to the Plan.
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`12.
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`By letters dated July 24, 2020, September 10, 2020, February 12, 2021, and July 1,
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`2021, Trustmark notified St. Luke’s of the $24,346.73 overpayment to which St. Luke’s was not
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`entitled, and Trustmark repeatedly demanded that St. Luke’s refund the Plan accordingly.
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`13.
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`To date, St. Luke’s refuses to respond to any of Trustmark’s correspondence and
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`has not refunded any part of the overpayment to the Plan.
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`14.
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`15.
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`As such, Trustmark brings forth this action so that justice may be served.
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`All conditions precedent have been met.
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`IV. CAUSES OF ACTION
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`A.
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`Restitution Pursuant to 29 U.S.C. § 1132(a)(3) to Recover Overpayment.
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`16.
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`Trustmark incorporates by reference each and every allegation set forth in the
`
`proceeding paragraphs 1 through 15 as if fully set forth herein.
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`PLAINTIFF’S ORIGINAL COMPLAINT
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` PAGE 3
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`Case 4:21-cv-02477 Document 1 Filed on 07/30/21 in TXSD Page 4 of 6
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`17.
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`St. Luke’s received an overpayment of $24,346.73 in benefits from the Plan to
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`which it was not entitled, and which in good conscious belongs to the Plan.
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`18.
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`Pursuant to the terms of the Plan, St. Luke’s is required to repay that sum back to
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`the Plan.
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`19.
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`Trustmark brings this claim for restitution as the Plan’s claims processor and on
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`behalf of the Plan, pursuant to 29 U.S.C. § 1132(a)(3), which authorizes Trustmark to obtain
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`“appropriate equitable relief… to enforce any provisions of the [ERISA] subchapter or the terms
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`of the [P]lan.”
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`20.
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`21.
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`The overpayment of $24,346.73 are explicitly identified and traceable to St. Luke’s.
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`St. Luke’s is liable to Trustmark and the Plan for the $24,346.73 overpayment and
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`should be ordered to repay this overpayment immediately.
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`B.
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`Unjust Enrichment.
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`22.
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`Trustmark incorporates by reference each and every allegation set forth in the
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`proceeding paragraphs 1 through 15 as if fully set forth herein.
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`23.
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`St. Luke’s has received an overpayment of $24,346.73 from the Plan through an
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`inadvertent error, to which it is not otherwise entitled.
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`24.
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`As a result of the $24,346.73 overpayment and St. Luke’s refusal to repay it to the
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`Plan, St. Luke’s has been unjustly enriched at the expense and to the detriment of the Plan.
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`25.
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`Trustmark, acting as the claims processor of the Plan, seeks recovery of the amount
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`by which St. Luke’s has been unjustly enriched.
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`C. Money Had and Received.
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`26.
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`Trustmark incorporates by reference each and every allegation set forth in the
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`proceeding paragraphs 1 through 15 as if fully set forth herein.
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`PLAINTIFF’S ORIGINAL COMPLAINT
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` PAGE 4
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`Case 4:21-cv-02477 Document 1 Filed on 07/30/21 in TXSD Page 5 of 6
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`27.
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`28.
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`29.
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`St. Luke’s holds money that in equity and good conscience belongs to the Plan.
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`St. Luke’s has failed to return such money to the Plan.
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`As a result, the Plan has incurred, and continues to incur, damages for which it now
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`sues and seeks relief from this Court.
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`V. REQUEST FOR RELIEF
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`WHEREFORE, the Plaintiff, Trustmark Health Benefits, Inc., requests that this Court enter
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`an order:
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`(A)
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`(B)
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`Entering a judgment ordering St. Luke’s to repay the Plan the overpayment;
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`Entering judgment in favor of Trustmark and awarding Trustmark its actual,
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`economic, and consequential damages against St. Luke’s for its refusal to
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`pay back the overpayment;
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`(C) Awarding Trustmark its attorneys’ fees and costs;
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`(D) Awarding Trustmark prejudgment and post-judgment interest as allowed by
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`law; and
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`(E) Granting Trustmark such other and further relief, both general and special,
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`at law and in equity, to which it may show itself justly entitled.
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`PLAINTIFF’S ORIGINAL COMPLAINT
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` PAGE 5
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`Case 4:21-cv-02477 Document 1 Filed on 07/30/21 in TXSD Page 6 of 6
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`Dated: July 30, 2021
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`PLAINTIFF’S ORIGINAL COMPLAINT
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`Respectfully submitted,
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`
`/s/ Andrew G. Jubinsky
`By:
`Andrew G. Jubinsky
`Texas Bar No. 11043000
`andy.jubinsky@figdav.com
`Nicole H. Muñoz
`Texas Bar. No. 24098153
`nicole.munoz@figdav.com
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`
`FIGARI + DAVENPORT, L.L.P.
`901 Main Street, Suite 3400
`Dallas, Texas 75202
`Telephone: (214) 939-2000
`Facsimile: (214) 939-2090
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`ATTORNEYS FOR PLAINTIFF TRUSTMARK
`HEALTH BENEFITS, INC.
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` PAGE 6
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