AMISUB (SFH), INC., dba Saint Francis Hospital; Saint Francis Hospital-Bartlett, Inc. v. Cigna Health and Life Insurance Company

RECOMMENDED FOR PUBLICATION
Pursuant to Sixth Circuit I.O.P. 32.1(b)
File Name: 25a0173p.06
UNITED STATES COURT OF APPEALS
FOR THE SIXTH CIRCUIT
AMISUB (SFH), INC., dba Saint Francis Hospital;
Saint Francis Hospital-Bartlett, Inc.,
Plaintiffs-Appellants,
v.
CIGNA HEALTH AND LIFE INSURANCE COMPANY,
Defendant-Appellee.
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No. 23-5714
Appeal from the United States District Court for the Western District of Tennessee at Memphis.
No. 2:21-cv-02308—John Thomas Fowlkes Jr., District Judge.
Argued: March 20, 2025
Decided and Filed: July 1, 2025
Before: CLAY, BUSH, and BLOOMEKATZ, Circuit Judges.
_________________
COUNSEL
ARGUED: Jonathan E. Siegelaub, LASH & GOLDBERG, LLP, Miami, Florida, for
Appellants. Warren Haskel, MCDERMOTT WILL & EMERY LLP, New York, New York, for
Appellee. ON BRIEF: Jonathan E. Siegelaub, Greg J. Weintraub, LASH & GOLDBERG,
LLP, Miami, Florida, Robert E. Cooper, David R. Esquivel, Sara K. Morgan, BASS, BERRY &
SIMS PLC, Nashville, Tennessee, for Appellants. Warren Haskel, Joshua B. Simon, Dmitriy
Tishyevich, John J. Song, MCDERMOTT WILL & EMERY LLP, New York, New York, for
Appellee.
_________________
OPINION
_________________
JOHN K. BUSH, Circuit Judge. Saint Francis Hospital and Saint Francis Hospital-
Bartlett (Hospitals), based in Tennessee, brought claims purporting to rely on their state’s
>

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common law for quantum meruit and unjust enrichment against Cigna Health and Life Insurance
Company, a Connecticut-based insurer. The Hospitals claim that Cigna, under its health
insurance policies, routinely pays less than reasonable value when the Hospitals provide
emergency care to Cigna members. The Hospitals have no contract with Cigna constraining the
amount the Hospitals can charge Cigna’s members for emergency services. In other words, the
Hospitals are, in insurance parlance, “out-of-network.” Nonetheless, the Hospitals argue they
have a quasi-contractual relationship with Cigna requiring it to pay more for emergency care
than what its health insurance contracts provide. They base their argument on federal and state
law requiring both that hospitals treat all emergency patients who need their care and that
insurers cover emergency care. Essentially, the Hospitals believe Cigna has a duty to pay the full
value of their services regardless of whether Cigna contracted with its members to limit its
liability.1
We hold Cigna has no such duty and affirm the district court’s judgment of dismissal.
I.
Before delving into the facts of this case, we review some background on the industry
and the legal scheme that existed during the events in question. A key distinction in health
insurance is that between “in-network” and “out-of-network” care. When a healthcare provider
has contracted with an insurer to set the prices the insurer and its members will pay, that provider
is considered in-network. Insurers generally promise that they will pay the full cost for care
from in-network providers, less cost-sharing amounts like copays, deductibles, and the like,
which the member pays. An insurer can reliably make such promises because these fixed-price
agreements limit the insurer’s risk. Out-of-network providers, in contrast, have no agreement
with the insurer setting prices in this manner. For care from out-of-network providers, an
insurer’s contract with its members will set out a formula for determining what it commits to
1We use reasonable value and full value interchangeably because they are the same in the context of
implied contracts. After all, there is no set price for a service provided under an implied contract. And the common
law would not compel a defendant to pay more than reasonable value for such a service. So, the service’s “full”
value should reach no higher than its reasonable value. It does not matter what sticker price, if any, the provider
puts on its service after the fact.

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pay. If the out-of-network provider charges more than that amount, the provider can—at least in
some instances—“balance bill” the patient for the difference.
When it comes to emergency services, this equation has more variables. The Emergency
Medical Treatment and Active Labor Act (EMTALA) mandates that emergency service
providers, like the Hospitals, provide stabilizing emergency care to patients who need it,
regardless of their ability to pay. 42 U.S.C. § 1395dd(b)(1). And under the Affordable Care Act
(ACA), insurers must provide “coverage” for many types of care, including emergency services.
42 U.S.C. § 18022(a)(1), (b)(1). A Tennessee statute likewise requires insurers to provide
“coverage” for emergency services.2 Tenn. Code Ann. § 56-7-2355(b)(1). The Hospitals claim
these laws put them at a disadvantage. According to this argument, because of EMTALA, Cigna
knows out-of-network emergency service providers like the Hospitals cannot refuse to do
business with Cigna members. So, the Hospitals believe, Cigna can and does underpay for out-
of-network emergency services, forcing providers to chase after patients to receive fair
compensation for their work.3
To the Hospitals’ credit, there is little doubt that balance billing causes problems for both
providers and patients. The nature of emergency care does not allow providers and patients to
agree to prices ahead of time. An out-of-network provider can balance bill and try to collect
from each patient after the fact, but doing so is costly. See Phillip Tseng et al., Administrative
Costs Associated with Physician Billing and Insurance-Related Activities at an Academic Health
Care System, 319 JAMA 691, 696 (2018). And many patients, quite simply, cannot pay. Liz
Hamel et al., Kaiser Fam. Found., The Burden of Medical Debt: Results from the Kaiser Family
Foundation/New York Times Medical Bills Survey 1 (2016), https://perma.cc/LC5P-PDTU.
A patient facing a balance bill can attempt to negotiate a lower price after receiving services.
2The Tennessee General Assembly amended the statute after the events of this case to require “coverage”
and “payment.” See 2022 Pub. Acts, c. 784, eff. April 8, 2022.
3It’s plausible that consumers take all this into account when choosing a health insurer—a consumer should
be willing to pay less for health insurance that provides less compensation to out-of-network emergency care
providers compared to insurance that provides more. In other words, it’s plausible that consumers know what they
are bargaining for and that therefore Cigna does not abuse EMTALA at the expense of providers and patients.
Because on a motion to dismiss we make all reasonable inferences in favor of the complaint, we do not adopt these
presumptions. Keene Grp., Inc. v. City of Cincinnati, 998 F.3d 306, 310 (6th Cir. 2021).

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But in reality, patients rarely do so, perhaps because they do not realize they can, lack the
expertise to know how much medical services are worth, or have minimal leverage. See Jennifer
A. Brobst, Open and Unashamed in an Era of Consumer Protection: Unconscionable Hospital
Billing Practices and the Chargemaster Racket, 51 U. Mem. L. Rev. 861, 879–80 (2021); Kelly
A. Kyanko & Susan H. Busch, Patients’ Success in Negotiating Out-of-Network Bills, 22 Am. J.
of Managed Care 647, 647 (2016) (study participants who tried to negotiate balance bills were
successful only 56% of the time). The Hospitals argue that insurers like Cigna are well
positioned to alleviate some of these burdens. Insurers are “better bargainer[s]” because they are
repeat players whose knowledge of the industry and control over many members’ coverage give
them the leverage to settle with providers faster and easier than individual patients could. See
Saul Levmore, Explaining Restitution, 71 Va. L. Rev. 65, 72–73 (1985). In short, we recognize
the industry-wide problem with balance billing for out-of-network emergency services that the
Hospitals seek to address with this suit.
Now to the facts of this case. The Hospitals had a price agreement with Cigna respecting
their emergency services, but that expired at the start of 2019. From then on, the Hospitals
provided emergency care to Cigna’s members as out-of-network providers. The Hospitals allege
that Cigna consistently underpaid them for their emergency care, often paying them less than it
paid to in-network providers. Given the systematic nature of the complaint’s allegations, the
Hospitals assert that their “legal claims are not based on alleged denials of benefits due under
ERISA plans. Instead, the Hospitals allege that Cigna breached independent equitable duties
owed directly to the Hospitals . . . to pay the reasonable value of the medical services rendered.”
Appellants Br. at 36. In other words, the Hospitals do not allege that Cigna failed to pay what its
plans promise.
Instead, the Hospitals argue that Cigna has a duty recognized by Tennessee common law
to pay the full cost of its members’ out-of-network emergency care, even if Cigna has contracted
with its members to limit the amount it will pay. The duty arises, they assert, because EMTALA
and the ACA (or Tennessee’s similar provision) force Cigna and the Hospitals to do business
together. This, according to the Hospitals, creates a quasi-contractual relationship, which would

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require Cigna under Tennessee law to pay reasonable costs for the Hospitals’ emergency
services.
On May 13, 2021, the Hospitals sued for quantum meruit, unjust enrichment, and breach
of implied-in-fact contract under Tennessee law. On appeal, the Hospitals have dropped their
breach of contract claim. And they have limited the scope of their quantum meruit and unjust
enrichment claims to care provided between January 1, 2019 and June 30, 2021.
The district court granted Cigna’s motion to dismiss under Federal Rules of Civil
Procedure 8 and 12(b)(6). It gave three grounds: (1) the complaint violated Rule 8’s pleading
standards by not pleading information specific to each instance of underpayment, (2) Tennessee
common law provides no basis for such a suit, and (3) ERISA preempts the ability of a state to
allow such a suit. We review de novo a Rule 12(b)(6) dismissal. Marchek v. United Servs. Auto.
Ass’n, 118 F.4th 830, 833 (6th Cir. 2024).
II.
We can decide this case on the Hospitals’ failure to plead a viable claim under Tennessee
common law, regardless of whether ERISA preemption applies. Because we can affirm on any
ground supported by the record, Hubbell v. FedEx SmartPost, Inc., 933 F.3d 558, 571 (6th Cir.
2019), we also need not consider the district court’s holding that the Hospitals should have
included claim-specific information in the complaint.
Again, the Hospitals brought claims for quantum meruit and unjust enrichment. The
elements of unjust enrichment in Tennessee are “1) a benefit conferred upon the defendant by the
plaintiff; 2) appreciation by the defendant of such benefit; and 3) acceptance of such benefit
under such circumstances that it would be inequitable for him to retain the benefit without the
payment of the value thereof.” Freeman Indus., LLC v. Eastman Chem. Co., 172 S.W.3d 512,
525 (Tenn. 2005) (cleaned up). Further, “a plaintiff need not establish that the defendant
received a direct benefit from the plaintiff. Rather, a plaintiff may recover for unjust enrichment
against a defendant who receives any benefit from the plaintiff if the defendant’s retention of the
benefit would be unjust.” Id. Claims for quantum meruit and unjust enrichment are “essentially
the same” in Tennessee law, Paschall’s, Inc. v. Dozier, 407 S.W.2d 150, 154 (Tenn. 1966), and

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the minor differences between them are not germane to this case, see Fam. Tr. Servs. LLC v.
Green Wise Homes LLC, 693 S.W.3d 284, 305–06 (Tenn. 2024).
The parties debate at length whether the Hospitals have conferred a legally cognizable
benefit on Cigna. Answering that question requires that we determine whether Cigna was
obligated to pay the full value of the services the Hospitals provided to Cigna’s members. If so,
then Cigna might have “retained an unjust economic benefit by withholding money that it would
otherwise be required to pay.” Prime Healthcare Servs. – Reno, LLC v. Hometown Health
Providers Ins. Co., No. 21-cv-00226, 2022 WL 1692525, at *8 (D. Nev. May 26, 2022); cf. Life
& Cas. Ins. Co. of Tenn. v. Baber, 79 S.W.2d 36, 38 (Tenn. 1935) (Insurer “cannot equitably be
allowed to retain any part of the premiums received, whilst it wrongfully deprives the insured of
all benefits which might hereafter arise to them from their payment.” (quoting Union Cent. Life
Ins. Co. v. Pottker, 33 Ohio St. 459, 467 (1878))). If not, then Cigna has met its legal
obligations. Cf. First Inv. Co. v. Allstate Ins. Co., 917 S.W.2d 229, 232 (Tenn. Ct. App. 1994)
(Insurer “cannot be held responsible for risks that it did not contractually assume.”).
To figure out what the law requires Cigna to pay, it helps to understand how Cigna
becomes a party to emergency care suits. Start with the obvious proposition that uninsured
patients are responsible for the full value of their care. Cigna only enters the picture if it
contracts with patients to shoulder the burden of paying for their care. As part of its cost-sharing
arrangement, Cigna only promised to pay for a portion of its members’ out-of-network
emergency care. Cigna’s members were liable for the rest. And the Hospitals do not allege that
Cigna failed to keep its end of the bargain. So, the Hospitals’ argument is essentially that the law
does not permit Cigna to contractually limit its liability in this way. For them to succeed, they
must establish that the cost-sharing arrangement between Cigna and its members for emergency
care was unlawful. But, as explained below, neither federal nor state law imposed a duty on
Cigna during the relevant period to pay the full cost of its members’ out-of-network emergency
care. The absence of such a duty sounds the death knell for the Hospitals’ claims.

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A. Whether Federal Law Compels Cigna to Pay Full Value
We first address federal law. The Hospitals point us to 42 U.S.C. § 18022, a provision of
the ACA requiring insurers to provide “coverage” for different categories of care, including
emergency services. We conclude this coverage requirement does not impose a duty on insurers
to cover the full cost of their members’ out-of-network emergency care.
Start with the text of the statute. The plain meaning of “coverage” does not imply that
the full cost of a harm will be covered. In an insurance context, “coverage” refers to the types of
harms that fall within the insurance contract. Coverage, Black’s Law Dictionary (9th ed. 2009)
(“Inclusion of a risk under an insurance policy; the risks within the scope of an insurance
policy.”); Merriam Webster’s Dictionary of Law (2011) (“a risk assumed by the terms of an
insurance contract”); Oxford English Dictionary (2d ed. 1989) (“The aggregate of risks covered
by an insurance policy.”); see also Bergmann v. Hutton, 101 P.3d 353, 358 (Or. 2004)
(interpreting “coverage” in a car insurance statute to mean “the universe of people, vehicles, and
events that trigger the insurer’s obligation to pay”).
The ACA adopts this common understanding of coverage. In the ACA, “health insurance
coverage” means the “benefits consisting of medical care . . . offered by a health insurance
issuer.” 42 U.S.C. § 300gg-91(b)(1). And § 18022 mandates that insurers offer “coverage that
. . . provides for . . . emergency services,” among other types of care. Id. § 18022(a), (a)(1),
(b)(1)(B). In other words, § 18022 tells insurers what types of care they must include in
members’ plans, but not how much they must pay providers.
The relevant federal agencies promulgated a regulation to fill in this detail. Cf. Wayman
v. Southard, 23 U.S. 1, 43 (1825). Specifically, 29 C.F.R. § 2590.715–2719A lays out three
methods for valuing a provider’s emergency services. It requires insurers to use whichever one
gives the provider the highest amount—called the “greatest-of-three” rule. See 29 C.F.R.
§ 2590.715–2719A(b)(3)(i). The regulation expressly recognizes that a provider can charge
more than the greatest-of-three amount and that it is the patient’s responsibility, not the insurer’s,
to pay the difference. See id. The Hospitals don’t challenge that regulation. Thus, the greatest-

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of-three rule helps to show that § 18022’s definition of “coverage” does not obligate an insurer to
pay the full value of emergency services.
Looking at § 18022 in its entirety supports the same conclusion. Recall that EMTALA
requires only emergency service providers—not other kinds of providers—to treat patients
regardless of their ability to pay. The Hospitals contend this makes emergency service providers
uniquely vulnerable to the threat of underpayment for their work. And they suggest that § 18022
fixed that problem by requiring insurers to pay the full value of members’ out-of-network
emergency care. But § 18022 requires insurers to provide “coverage” for far more than just
emergency services, including mental health treatment, prescription drugs, laboratory services,
chronic disease management, and pediatric services. See 42 U.S.C. § 18022(b)(1)(E)–(J). The
Hospitals do not argue that § 18022 requires insurers to pay the full cost of all those services
from an out-of-network provider. For us to hold as much would shock the healthcare system and
dramatically diminish the up-to-now critical distinction between in-network and out-of-network
care.
Further, after the events at issue in this lawsuit, Congress enacted the No Surprises Act
(NSA), which gave providers an avenue to seek full reimbursement from insurers for their
members’ out-of-network emergency care. See 134 Stat. 2759–60, codified at 42 U.S.C.
§ 300gg-111(a)(1)(C)(iv)(II). That is exactly the relief the Hospitals want here. Yet “[t]he very
fact that it was thought necessary to incorporate this provision in the [NSA] is a recognition that
the pre-existing legislation did not have that effect.” Nagle v. Loi Hoa, 275 U.S. 475, 481
(1928); see also Rotkiske v. Klemm, 589 U.S. 8, 14 (2019) (“Atextual judicial supplementation is
particularly inappropriate when, as here, Congress has shown that it knows how to adopt the
omitted language or provision.”). The NSA also prohibits balance billing patients for out-of-
network emergency services, suggesting Congress’s awareness that under § 18022, emergency
providers were not fully compensated for the full value of their services and would directly
charge patients. Notably too, unlike § 18022, the NSA addresses only the provision of
emergency services and one other type of care.4 In sum, § 18022 was not Congress’s fix to the
4The other type of care is “non-emergency services performed by nonparticipating providers at certain
participating facilities.” 134 Stat. 2768, codified at 42 U.S.C. § 300gg-111(b). This subsection is commonly

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problem of insurers underpaying out-of-network emergency care providers; the NSA was.
Indeed, large parts of the NSA would have been unnecessary had § 18022 been interpreted as the
Hospitals contend.
For these reasons, we conclude the ACA’s coverage requirement does not impose a duty
on insurers to cover the full cost of their members’ out-of-network emergency care.
B. Whether Tennessee Law Compels Cigna to Pay Full Value
The Hospitals’ argument fares no better under Tennessee law. During the events
underlying this suit, Tenn. Code Ann. § 56-7-2355(b)(1) only required insurers to provide
“coverage” for emergency services, just like the ACA. Tennessee enacted its statute a little more
than a decade before Congress enacted the ACA, but we have seen no evidence that the meaning
of “coverage” changed. See 1997 Pub. Acts, c. 524, eff. June 19, 1997. And the only Tennessee
court that has analyzed § 2355(b)(1) did not allow the same type of suit that the Hospitals bring
here. See HCA Health Servs. of Tenn., Inc. v. BlueCross BlueShield of Tenn., Inc., No. M2014–
01869–COA–R9–CV, 2016 WL 3357180 (Tenn. Ct. App. June 9, 2016). So we are not
convinced that § 2355(b)(1) imposes the duty upon insurers that the Hospitals need.
The last place for the duty to exist is in Tennessee common law. The Hospitals cite
various authorities to suggest that Tennessee common law independently imposes an equitable
duty on insurers to pay the full cost of their insureds’ out-of-network emergency care: River Park
Hospital, Inc. v. BlueCross BlueShield of Tennessee, Inc., 173 S.W.3d 43 (Tenn. Ct. App. 2002),
the Restatement (Third) on Restitution and Unjust Enrichment, and a series of out-of-state cases.
None persuades.
1. River Park
Let’s turn to River Park. There, River Park Hospital sued BlueCross BlueShield, an
insurer, alleging that BlueCross underpaid for emergency services River Park provided to
understood to “protect[] patients from being billed by out-of-network doctors who provide treatment at in-network
hospitals.” Stephanie Armour, Patients to Be Protected from Surprise Billing Under New Rule, Wall St. J. (July 1,
2021), https://perma.cc/8ZYY-B6K4.

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Tennessee Medicaid recipients that BlueCross covered. River Park, 173 S.W.3d at 49–50.
Importantly, Tennessee contracted with BlueCross to cover the full cost of Medicaid
beneficiaries’ care in exchange for a flat, monthly fee. Id. at 49.
This arrangement proved dispositive in River Park. Id. at 59–60. As in our case,
EMTALA forced River Park Hospital to treat patients. Id. at 59. Also as in our case, the
question was how far the insurer’s duty to pay extended. But in River Park, BlueCross’s
contract with Tennessee imposed a duty on it to cover the full cost of the Medicaid beneficiaries’
care. The court could therefore allow an unjust enrichment claim against BlueCross, whether or
not a statutory duty existed. Id. River Park Hospital entered the implied contract by virtue of
EMTALA, and BlueCross entered it (up to the full cost of the Medicaid beneficiaries’ care) by
virtue of its contract with the state. Id.
Here, by contrast, the insurer has no contractual duty to pay the full cost of its members’
emergency care. Cigna has only agreed to cover a portion of out-of-network emergency
services, and the Hospitals do not argue that these plans violated the ACA’s greatest-of-three
rule. So even if we were certain that Cigna entered into a quasi-contractual relationship with the
Hospitals, that implied contract would not compel Cigna to pay the full value of the Hospitals’
services. River Park does not support a reading of Tennessee common law to hold otherwise.5
2. The Restatement
The Hospitals next cite an illustration in the Restatement to argue that an emergency care
provider can recover in a scenario like theirs. See Restatement (Third) of Restitution and Unjust
Enrichment § 22, cmt. g, illus. 10. That illustration cites River Park. See id. reporter’s note g.
But if the Restatement stands for what the Hospitals claim, then it demonstrates a flawed
understanding of River Park. It would ignore that the insurer in River Park had contracted to
fully cover the Medicaid beneficiaries’ emergency care. River Park, 173 S.W.3d at 49. We
therefore hesitate to apply the Hospitals’ reading of the Restatement here, where that key
predicate is missing.
5An unpublished Tennessee case reached the same conclusion under similar facts, strengthening our
confidence in this analysis. See HCA, 2016 WL 3357180, at *11–12.

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The Hospitals point to only one case, rendered by a district court under New York law,
that has adopted this illustration from the Restatement. See Emergency Physician Servs. of N.Y.
v. UnitedHealth Grp., Inc., 749 F. Supp. 3d 456, 474–75 (S.D.N.Y. 2024). But that district
court, in addition to citing the Restatement, adopted its rule from a state trial court whose case
involved a Medicare insurer with a duty to fully cover its beneficiaries’ care, like the Medicaid
insurer in River Park. See N.Y.C. Health & Hosps. Corp. v. Wellcare of N.Y., Inc., 937 N.Y.S.2d
540, 542–43 (Sup. Ct. 2011) (“Wellcare”). The district court in Emergency Physician Services
did not account for the key fact that Medicare obligated the insurer in Wellcare to provide full
coverage.6 The non-Medicaid provider in HCA, by contrast, had no such obligation, as the
Tennessee Court of Appeals recognized. See HCA, 2016 WL 3357180, at *11–12. Similarly, no
such obligation may be imposed on Cigna, the insurer in this case who is not sued as a Medicaid
provider. Consequently, neither the district court decision from New York nor the Restatement
is sufficiently on point to persuade us to adopt the Hospitals’ position.
3. Out-of-State Cases
The other cases that the Hospitals cite involve circumstances meaningfully different from
those here. Three concern Medicaid insurers like River Park did.7 One relates to a provider
suing based on the terms of the insurer’s plan, which the Hospitals say they are not doing. Prime
Healthcare, 2022 WL 1692525, at *1–2. One involves a defendant insurer who only objected
based on the provider’s failure to plead specific instances of underpayment, like the Rule 8 issue
here that we have declined to address. Aetna Life Ins. Co. v. Huntingdon Valley Surgery Ctr.,
No. 13-CV-03101, 2015 WL 1954287, at *10 (E.D. Pa. Apr. 30, 2015). In another, the district
court allowed a case to survive a motion to dismiss only because the provider pled that it
conferred a benefit on the insurer, without analyzing whether such a claim was legally
6After oral argument in this case, the Nevada Supreme Court issued its decision in UnitedHealthCare Ins.
Co. v. Fremont Emergency Servs. (Mandavia), Ltd, __P.3d__, 2025 WL 1667716 (Nev. 2025). That court found the
Restatement and Emergency Physician Services persuasive, without adding analysis of its own. For the reasons
stated, those sources do not persuade us, so neither does Fremont.
7Appalachian Reg’l Healthcare v. Coventry Health & Life Ins. Co., No. 12-CV-114, 2013 WL 1314154
(E.D. Ky. Mar. 28, 2013); Temple Univ. Hosp., Inc. v. Healthcare Mgmt. Alternatives, Inc., 832 A.2d 501 (Pa.
Super. Ct. 2003); N.Y.C. Health & Hosps. Corp. v. Wellcare of N.Y., Inc., 937 N.Y.S.2d 540 (Sup. Ct. 2011).

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cognizable. HCA Health Servs. of Virginia, Inc. v. CoreSource, Inc., No. 3:19-CV-406, 2020
WL 4036197, at *6 (E.D. Va. July 17, 2020).
The rest of the cases are from Florida.8 These are inapplicable because Florida had
enacted a state-law version of the NSA, imposing a statutory duty on insurers to pay the full
value of their members’ out-of-network emergency care. Fla. Stat. §§ 627.64194, 641.513.
Tennessee had no such statutory scheme during the events of this case.
* * *
In sum, aside from pointing to opinions from one district court and one state court that
did not consider the necessity of an insurer having a duty to fully cover emergency care, the
Hospitals cite no case supporting their cause of action absent a statute or regulation imposing this
duty on insurers.
III.
In the final analysis, the Hospitals’ theory for recovery under Tennessee common law is
essentially a challenge to the cost sharing arrangement between Cigna and its members. For the
period at issue, Cigna’s method for splitting costs with its members did not offend federal or
state statutory law. And Tennessee common law did not impose its own equitable obligation to
that effect either.
Consequently, we AFFIRM the district court’s dismissal of the Hospitals’ complaint.
Because this holding disposes of all the claims here, we need not reach the question of whether
ERISA would preempt Tennessee from imposing such a duty as a regulation of cost sharing
instead of a regulation of the price of healthcare services. We also DENY the Hospitals’ motion
to certify a question of law to the Tennessee Supreme Court.
8Surgery Ctr. of Viera, LLC v. UnitedHealthcare, Inc., 465 F. Supp. 3d 1211 (M.D. Fla. 2020); S. Broward
Hosp. Dist. v. ELAP Servs., LLC, No. 20-CV-61007, 2020 WL 7074645 (S.D. Fla. Dec. 3, 2020); Baptist Hosp. of
Miami, Inc. v. Medica Healthcare Plans, Inc., 385 F. Supp. 3d 1289 (S.D. Fla. 2019); Nat’l Lab’ys, LLC v. United
Healthcare Grp., Inc., No. 17-CV-81178, 2018 WL 11260511 (S.D. Fla. Apr. 4, 2018); Reva, Inc. v. Humana
Health Benefit Plan of La., Inc., No. 18-20136-CIV, 2018 WL 1701969 (S.D. Fla. Mar. 19, 2018); Merkle v. Health
Options, Inc., 940 So. 2d 1190 (Fla. Dist. Ct. App. 2006).

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