Patricia Young v. Community Health Systems, Inc, et al

[DO NOT PUBLISH]
In the
United States Court of Appeals
For the Eleventh Circuit
____________________
No. 22-14255
Non-Argument Calendar
____________________
PATRICIA YOUNG,
on behalf of herself and all others similarly situated,
Plaintiff-Appellant,
versus
COMMUNITY HEALTH SYSTEMS, INC,
HERNANDO HMA, LLC,
d.b.a. Bravera Health Brooksville,
JOHN DOES 1-5,
CHSPSC, LLC,
CHS/COMMUNITY HEALTH SYSTEMS, INC.,
Defendants-Appellees.
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2 Opinion of the Court 22-14255
____________________
Appeal from the United States District Court
for the Middle District of Florida
D.C. Docket No. 8:22-cv-00329-SCB-AEP
____________________
Before J ORDAN, BRANCH , and B RASHER , Circuit Judges.
PER CURIAM:
Plaintiff Patricia Young went to the emergency room after a
bicycle accident. Upon receiving her bill, she noticed she had been
charged nearly $4,000 for an “ER Visitation Fee.” Believing the fee
to be unlawful, she brought this suit against defendants Commu-
nity Health Systems, Inc., Hernando HMA, LLC, d.b.a. Bravera
Health Brooksville, CHSPCS, LLC, CHS/Community Health Sys-
tems, Inc., and John Does 1–5. The distinctions between these de-
fendants are irrelevant for purposes of this appeal; for ease of read-
ing, we refer to all defendants collectively as “the Hospital.”
Young alleged violations of Florida’s Deceptive and Unfair
Trade Practices Act and Florida common law. The district court
dismissed Young’s suit after concluding that her operative com-
plaint failed to state any plausible claim to relief. Young appealed.
We affirm.
I.
This appeal comes to us at the motion-to-dismiss stage. Ac-
cordingly, the following recitation of background facts comes
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22-14255 Opinion of the Court 3
primarily from Young’s operative complaint, with the allegations
in that complaint taken as true. Newbauer v. Carnival Corp., 26 F.4th
931, 934 (11th Cir. 2022). In most appeals at this stage, the operative
complaint would be the only source of factual information. But the
nature of this suit and the parties’ arguments require us to look at
two pieces of evidence submitted by the Hospital. One piece of ev-
idence is the contract at the center of this lawsuit. That contract is
central to Young’s case, so we treat it as a part of the complaint
itself. See Harris v. Ivax Corp., 182 F.3d 799, 802 n.2 (11th Cir. 1999).
The other piece of evidence is the uncontroverted testimony of the
Hospital’s Chief Administrative Officer. We use that testimony for
the limited purpose of ensuring that we have jurisdiction over
Young’s appeal. See Houston v. Marod Supermarkets, Inc., 733 F.3d
1323, 1335–36 (11th Cir. 2013).
This dispute arises from Young’s visit to the Hospital after a
bicycle accident. While in the emergency room, Young was pre-
sented with the Hospital’s standardized Consent for Service Agree-
ment. As is relevant here, the Agreement laid out Young’s financial
obligations. Specifically, the Agreement contained a promise from
Young to pay the Hospital “in accordance with the regular rates
and terms of the Facility.” Young executed the Agreement, re-
ceived treatment, and was discharged from the Hospital.
Young’s hospital bill totaled $7,543.64. The Hospital later
gave Young a discount, bringing her total down to $5,657.74. State
Farm Auto Insurance paid the Hospital $4,526.19 on Young’s be-
half; Young remained responsible for the remaining $1,131.55.
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4 Opinion of the Court 22-14255
Eventually, the Hospital referred the $1,131.55 debt to a collection
agency, but it appears that the agency’s efforts were fruitless. The
Hospital’s Chief Administrative Officer testified in the district court
that, shortly after Young filed this lawsuit, the Hospital discharged
Young’s debt and waived any legal right to collect from Young.
There is no allegation that Young ever spent any of her own money
to pay off the amount that remained after State Farm’s payment to
the hospital. Young alleges, however, that the agency’s collection
efforts harmed her credit score and caused her to suffer emotional
distress.
Young takes issue with one line item on her hospital bill: an
“ER Visitation Fee” of $3,922.68. She alleges that it is the Hospital’s
practice to charge every emergency room patient an ER Visitation
Fee, but that she had no knowledge of, and no reasonable way of
learning about, that practice prior to signing the Agreement. More
specifically, Young alleges that no Hospital employee notified her
about the ER Visitation Fee before she agreed to receive treatment
at the Hospital, that the Agreement did not alert her to such a fee,
that the Hospital’s website is silent about the fee, and that the Hos-
pital in no other way informed her that an ER Visitation Fee would
be charged. Young also says that, had she been made aware of the
ER Visitation fee, she would have gone elsewhere for medical
treatment. Young believes that the Hospital purposefully hid its ER
Visitation Fee until after Young had agreed to receive treatment.
That alleged intentional concealment, Young says, violated Flor-
ida’s Deceptive and Unfair Trade Practices Act, constituted a ma-
terial breach of the Agreement, and amounted to a breach of
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22-14255 Opinion of the Court 5
Florida’s common law duty to disclose material information during
contract negotiations.
The district court dismissed Young’s suit. Young appealed.
We affirm.
II.
We review de novo a plaintiff’s standing. SEC v. Quest Energy
Mgmt. Grp., Inc., 768 F.3d 1106, 1108 (11th Cir. 2014). We also re-
view de novo a district court’s dismissal for failure to state a claim.
See Butler v. Sheriff of Palm Beach Cnty., 685 F.3d 1261, 1265 (11th Cir.
2012).
III.
Young contends that the district court should be reversed
because it misapplied Florida law. The Hospital, in addition to de-
fending the district court’s decisions, contends that Young lacks Ar-
ticle III standing. If true, the district court was without jurisdiction
to entertain Young’s lawsuit. Bochese v. Town of Ponce Inlet, 405 F.3d
964, 974–75 (11th Cir. 2005). Accordingly, our analysis must begin
with the threshold issue of standing. Id.
A.
Young bears the burden of establishing Article III standing.
Spokeo, Inc. v. Robins, 578 U.S. 330, 338 (2016). Young has standing
only if (1) she has suffered an injury in fact, (2) her injury is fairly
traceable to the Hospital’s allegedly unlawful conduct, and (3) the
relief she seeks will likely redress the injury she has suffered. Id. A
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6 Opinion of the Court 22-14255
plaintiff must have standing for each form of relief sought.
TransUnion LLC v. Ramirez, 141 S. Ct. 2190, 2208 (2021). Young
seeks declaratory and injunctive relief prohibiting the Hospital
from imposing ER Visitation Fees in the future. She also seeks
monetary damages to compensate her for the harm she has suf-
fered as a result of the Hospital’s attempts to collect payment for
the ER Visitation Fee.
Young lacks standing to pursue claims for declaratory or in-
junctive relief. Those forms of relief either stop an ongoing harm
or prevent a future harm. Thus, Young must establish that she is
suffering an ongoing harm or in danger of suffering a harm in the
near future. Elend v. Basham, 471 F.3d 1199, 1207–08 (11th Cir.
2006). No such showing has been made. There’s no allegation or
evidence that the Hospital will subject Young to another ER Visit-
ation Fee in the future—indeed, Young’s complaint leads one to
believe that she will no longer go to the Hospital for treatment as
long as the Hospital continues to charge the fee. And although
Young’s complaint originally alleged some ongoing harms associ-
ated with the ER Visitation Fee already charged—i.e., the conse-
quences of the Hospital’s continued collection efforts—those
harms have ended. The Hospital discharged the debt and, through
the uncontroverted sworn testimony of its Chief Administrative
Officer, affirmatively waived any legal right to collect the $1,131.55
that was outstanding when Young commenced this action.
Young does have standing, however, to seek compensatory
damages. The Hospital’s argument to the contrary is premised on
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22-14255 Opinion of the Court 7
State Farm’s $4,526.19 payment to the Hospital on behalf of Young.
As the Hospital sees things, the $4,526.19 State Farm payment
should be considered to have taken care of the $3,922.68 ER Visit-
ation Fee, such that Young was never responsible for paying the
ER Visitation Fee. Thus, the argument goes, the imposition and
collection of the ER Visitation Fee never injured Young; any ad-
verse effect to Young was caused by the remaining $1,131.55,
which comprised charges to which Young has never objected.
The Hospital’s argument misses the mark. Even if the State
Farm payment is treated as full payment for the ER Visitation Fee,
the imposition and attempted collection of the ER Visitation Fee
still injured Young. Young still owed $1,131.55 after accounting for
State Farm’s payment. When Young could not or would not pay,
the Hospital referred the debt for collection. Young alleges those
collection efforts negatively impacted her credit score and caused
her emotional distress. Had the ER Visitation Fee never been im-
posed, State Farm’s payment would have covered the entire bill.
So Young’s injuries were caused by the allegedly unlawful ER Vis-
itation Fee, and an award of monetary damages would redress her
injuries.
B.
Assured of our jurisdiction, we now turn to the merits of
Young’s appeal. She contests the district court’s dismissal of her
Florida Deceptive and Unfair Trade Practices Act claim and her
Florida common law claims for failure to disclose and for breach of
contract. In the operative complaint, Young accused the Hospital
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8 Opinion of the Court 22-14255
of violating Florida Statutes section 395.301. The district court did
not directly address that argument, and Young only mentions the
statute twice in passing in her briefing on appeal. Accordingly, we
do not consider any section 395.301 claim as being at issue in
Young’s appeal.
All of Young’s claims arise under Florida substantive law, so
we look first to the Florida Supreme Court for guidance. If the Flor-
ida Supreme Court has not decided an issue of state law, “we are
bound to adhere to decisions of the state’s intermediate appellate
courts absent some persuasive indication that the state’s highest
court would decide the issue otherwise.” Winn-Dixie Stores, Inc. v.
Dolgencorp, LLC, 746 F.3d 1008, 1021 (11th Cir. 2014) (quotation
marks and citation omitted).
1.
The district court correctly dismissed Young’s FDUTPA
claim. FDUTPA provides that “[a]n act or practice required or spe-
cifically permitted by federal or state law” can never violate the
statute. Fla. Stat. § 501.212(1). Florida courts have treated this so-
called “safe harbor” as prohibiting a plaintiff from using FDUTPA
to create new obligations, or to broaden existing obligations, when
a defendant’s conduct is already in compliance with federal law or
regulations. See Eirman v. Olde Disc. Corp., 697 So. 2d 865, 866 (Fla.
Dist. Ct. App. 1997). So, if a defendant complies with federal infor-
mation-disclosure laws or regulations, then no FDUTPA claim lies
for insufficient disclosure. See Prohias v. AstraZeneca Pharms., L.P.,
958 So. 2d 1054 (Fla. Dist. Ct. App. 2007).
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22-14255 Opinion of the Court 9
Young’s FDUTPA claim is barred by the safe harbor. Disclo-
sure of costs associated with medical treatment is a subject of fed-
eral law. See 42 U.S.C. § 300gg-18(e). Regulations promulgated pur-
suant to section 300gg-18(e) seek “to promote greater price trans-
parency for patients . . . .” 83 Fed. Reg. 41144, 41686. Indeed, the
Centers for Medicare and Medicaid Services specifically recognized
“patients being surprised by facility fees . . . for emergency depart-
ment visits” as a focus of the regulations relevant to this case. Id.
Young’s complaint acknowledges that the Hospital’s chosen
method of compliance with federal law is publishing online a list—
known as a “chargemaster”—of items, services, and other costs as-
sociated with receiving treatment. And Young has explicitly de-
clined to allege or otherwise argue that the ER Visitation Fee is not
disclosed in the chargemaster. So Young has conceded that,
through publication of the chargemaster, the Hospital has com-
plied with the applicable federal regulations. That concession
places Young’s claim squarely within FDUTPA’s safe harbor.
Young tries to get around the safe harbor by recharacteriz-
ing the Hospital’s allegedly unlawful conduct. Young wants this to
be a case about the Hospital intentionally hiding the ER Visitation
Fee from prospective patients. That theory assumes, however, that
the ER Visitation Fee was hidden. And that assumption is in direct
conflict with Young’s concession that the Hospital—in compliance
with federal law—published its ER Visitation Fee in the chargemas-
ter. So this cannot be a case about “concealing” the ER Visitation
Fee. This case can be viewed only as a challenge to the way the ER
Visitation Fee was disclosed. Because the Hospital’s method of
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10 Opinion of the Court 22-14255
disclosure complied with federal information disclosure laws and
regulations, Young’s claim is barred by FDUTPA’s safe harbor.
2.
Young’s common law failure-to-disclose claim is also insuf-
ficiently pleaded. Under Florida law, “[a] defendant’s knowing con-
cealment or non-disclosure of a material fact may only support an
action for fraud where there is a duty to disclose.” R.J. Reynolds To-
bacco Co. v. Whitmire, 260 So. 3d 536, 538 (Fla. Dist. Ct. App. 2018)
(quoting TransPetrol, Ltd. v. Radulovic, 764 So. 2d 878, 879 (Fla. Dist.
Ct. App. 2000)). “This duty arises when one party has information
which the other party has a right to know because there is a fiduci-
ary or other relation of trust or confidence between the two par-
ties.” Friedman v. Am. Guardian Warranty Servs., Inc., 837 So. 2d
1165, 1166 (Fla. Dist. Ct. App. 2003). “In a commercial transaction
in which ‘the parties are dealing at arm’s length, a fiduciary rela-
tionship does not exist because there is no duty imposed on either
party to protect or benefit the other.’” R.J. Reynolds Tobacco Co., 260
So. 3d at 539 (quoting Taylor Woodrow Homes Fla., Inc. v. 4/46-A
Corp., 850 So. 2d 536, 541 (Fla. Dist. Ct. App. 2003)). The district
court concluded, and Young does not dispute, that Young’s opera-
tive complaint did not allege facts giving rise to a fiduciary relation-
ship or other traditional relationship of trust or confidence.
In response to the district court, Young argues that the ab-
sence of a fiduciary relationship should not be dispositive. She con-
tends that the Hospital was “in a superior bargaining position” be-
cause it held “specialized knowledge of [its] billing practices” and
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22-14255 Opinion of the Court 11
because Young “was physically injured at the time the parties con-
tracted,” such that Young “lacked the ability to agree or disagree
with an undisclosed fee imposed on her without her knowledge.”
To justify a diversion from the general rules of contract law, a dis-
parity in bargaining power must be so “substantial” that it is “over-
whelming.” See VoiceStream Wireless Corp. v. U.S. Commc’ns, Inc.,
912 So. 2d 34, 39 (Fla. Dist. Ct. App. 2005); Ware Else, Inc. v. Ofstein,
856 So. 2d 1079, 1081–82 (Fla. Dist. Ct. App. 2003). There’s nothing
to suggest that level of disparity here.
For starters, the idea that Young’s injuries rendered her in-
capable of effectively negotiating with the Hospital contradicts her
allegation that, had she known about the ER Visitation Fee, she
would have sought treatment elsewhere. Young was either too in-
jured to negotiate or she was healthy enough to take her business
elsewhere—she cannot have it both ways. The allegation that she
would have gone elsewhere for medical attention is in the opera-
tive complaint and thus controls over the too-hurt-to-negotiate ar-
gument raised in her briefing. See Miccosukee Tribe of Indians of Fla.
v. United States, 716 F.3d 535, 559 (11th Cir. 2013) (noting that “a
plaintiff cannot amend his [or her] complaint through argument . .
.”). Young’s argument also seems to assume that the Hospital knew
the exact amount of the ER Visitation Fee. But her complaint al-
leges that the amount charged fluctuates and is not even deter-
mined until after a patient’s discharge. So on the face of Young’s
own complaint, it was impossible for the Hospital to disclose the
exact amount of the ER Visitation Fee at the time she signed the
Agreement.
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12 Opinion of the Court 22-14255
Given the facts alleged in Young’s complaint, the text of the
Agreement, and her concessions about the content of the Hospi-
tal’s online chargemaster, there is little to distinguish the ER Visit-
ation Fee from the cost of treatment. The Agreement contains a
general promise from Young to pay according to the Hospital’s
“regular rates and terms . . . .” At the time she executed the Agree-
ment, the Hospital did not know the amount it would charge
Young for either treatment or the ER Visitation Fee: both amounts
would ultimately depend on things yet to occur. The Hospital did
disclose, via its online chargemaster, the existence and range of
costs of the ER Visitation Fee—just as it did with the usual costs of
its offered medical services. Young makes no suggestion, however,
that the Hospital unlawfully failed to disclose information relating
to costs of treatment. She has not persuaded us that the two should
be viewed differently.
3.
We cannot say Young’s breach of contract claim was erro-
neously dismissed. A breach of contract claim arises when a defend-
ant fails to make good on a contractual promise. E.g., Friedman v.
New York Life Ins. Co., 985 So. 2d 56, 58 (Fla. Dist. Ct. App. 2008).
But Young does not identify any promise that the Hospital made
then failed to keep. Instead, Young’s argument is that charging her
the ER Visitation Fee breached the Agreement because (1) the
Agreement authorized only the imposition of service-related
charges, but (2) the ER Visitation Fee “covers overhead, adminis-
trative, and operational expenses.” The district court rejected both
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22-14255 Opinion of the Court 13
premises. The district court first concluded that the ER Visitation
Fee is not the administrative charge that Young made it out it to
be. The district court then decided that no matter how one de-
scribes the ER Visitation Fee, the Agreement nonetheless author-
ized the Hospital’s imposition of the fee.
In her initial brief on appeal, Young challenges only the dis-
trict court’s first conclusion. It is not until her reply brief that she
lays out an argument against the district court’s second conclusion.
Young’s failure to include in her initial brief the attack on the dis-
trict court’s second conclusion means that second conclusion is not
at issue in this appeal. See Williams v. Obstfeld, 314 F.3d 1270, 1278–
79 n.9 (11th Cir. 2002). And that unchallenged conclusion by the
district court is sufficient on its own for us to affirm the dismissal
of Young’s breach of contract claim.
IV.
The judgment of the district court is AFFIRMED.
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