Healthcare Ally Mgmt. of Cal., LLC v. WSP USA, Inc., __ F.4th __, 2026 WL 2319896 (9th Cir. Aug. 11, 2026, No. 24-3479)
Before performing surgery, out-of-network provider La Peer Surgery Center called Aetna, which administered the patient’s ERISA healthcare plan for employer WSP USA. Aetna represented that the patient would pay a portion of the surgery’s expenses and WSP’s plan would pay the balance at the “usual, customary, and reasonable” (“UCR”) rate, rather than the lower Medicare Fee Schedule rate. Relying on this, La Peer performed the surgery. The plan then paid only the Medicare rate (about five percent of La Peer’s bill). LaPeer’s successor (HAMOC) sued WSP and Aetna for negligent misrepresentation, promissory estoppel, and failure to pay ERISA plan benefits under 29 U.S.C.A. § 1132(a)(1)(B). The district court dismissed the ERISA claim for lack of derivative standing and dismissed the state law claims as preempted by ERISA. HAMOC appealed.
The Ninth Circuit affirmed in part and reversed in part. Applying the “connection with” and “reference to” preemption tests, the court held ERISA did not preempt HAMOC’s negligent misrepresentation claim. Under the “connection with” test, the La Peer-Aetna relationship fell outside ERISA’s regulatory scope because ERISA provides no cause of action for providers, indicating Congress did not intend to regulate their relationship with plan administrators. Under the “reference to” test, the claim did not hinge on the denial of benefits to the patient (who received covered treatment) or the accuracy of Aetna’s final coverage decision, but on the inconsistency between Aetna’s pre-surgery representations and post-surgery conduct. Because the claim was not one the patient could have asserted under ERISA, it could stand alone without reference to the ERISA plan.
The court distinguished Bristol SL Holdings, Inc. v. Cigna Health & Life Ins. Co., 103 F.4th 597 (9th Cir. 2024), which held ERISA preempted breach of contract and promissory estoppel claims. HAMOC’s misrepresentation claim did not seek to supplant a plan governing the relationship between two ERISA entities.
