United States: Eleventh Circuit Affirms ADA Preemption Of Class Action Claims That Restrict Air Ambulance Operator's Prices

Judith R Nemsick is a litigation attorney in Holland & Knight's New York office


  • Airline Deregulation Act (ADA) preempts class action claims seeking to enforce Florida statute that limits an air ambulance operator's prices by prohibiting balance billing of unpaid invoices.
  • McCarran-Ferguson Act does not reverse preempt the ADA because the Florida statute does not regulate the "business of insurance" – the statute affects the billing and pricing practices of medical providers only with respect to insureds, and has nothing to do with the policy relationship between an insurer and an insured.

In a significant decision for the air ambulance industry, the U.S. Court of Appeals for the Eleventh Circuit held that the Airline Deregulation Act (ADA) preempts enforcement of a Florida law limiting an air ambulance operator's ability to collect unpaid amounts on its invoices. The decision, Bailey v. Rocky Mountain Holdings LLC,2 affirms the district court's dismissal of a proposed class action against the operator.

The ADA, which applies to air ambulance operators, prohibits states from enacting or enforcing laws "related to a price, route or service of an air carrier."3 The Eleventh Circuit panel agreed with the district court that Florida's Personal Injury Protection (PIP) statute4 improperly restricted an air ambulance operator's prices by first limiting the reimbursement for such services to a schedule of charges based on Medicare rates and then prohibiting the operator from billing the insured for the balance of the unpaid invoices.

District Court's Summary Judgment Holding

The action centered on air ambulance services provided to transport plaintiff's son to a hospital following an automobile accident. Seeking reimbursement, the operator billed the plaintiff's automobile insurer for the air ambulance services. The insurer reimbursed the operator pursuant to the PIP statute, which permitted reimbursement at 80 percent of the statutory fee for air ambulance services up to the policy's limits. The operator sought the unpaid balance from plaintiff, as the insured.

Plaintiff commenced a class action contending that the PIP statute's "balance billing provision" prohibited the operator from attempting to bill for "any amount in excess of such limits, except for amounts not covered by the insured personal injury coverage due the coinsurance amount or maximum policy limits."5 The court disposed of the claim by granting summary judgment to the operator on ADA preemption grounds, finding that the claims "directly challeng[ed]" the operator's prices and "naturally affect[ed]" its services.6

Eleventh Circuit Affirms Preemption Ruling

On appeal, the Eleventh Circuit affirmed and concluded that the action "[fell] squarely within the preemptive intent behind the ADA." The panel found that application of the PIP statute had a "forbidden effect" on the operator's prices because it "prohibit[ed] medical providers from charging in excess of the fee schedule amount" and therefore "operate[ed] as a 'state-imposed regulation' on air carrier rates."7

Like the district court, the panel rejected the argument that the McCarran-Ferguson Act (MFA) reverse preempts the ADA. Under the MFA, states retain authority to regulate the relationship between insurance companies and their policyholders. As such, state laws that regulate the business of insurance preempt any conflicting federal law unless that federal law specifically relates to the business of insurance.8 To determine whether a state law was enacted for the purpose of regulating the "business of insurance," the law must satisfy a three-part test: "first, whether the practice has the effect of transferring or spreading a policyholder's risk; second, whether the practice is an integral part of the policy relationship between the insurer and insured; and third, whether the practice is limited to entities within the industry."9

Because the "balance billing provision," i.e., the state law, "affects the billing and pricing practices of medical providers only with respect to insureds," the panel held that it "has nothing to do with the relationship between an insurer and an insured and therefore does not regulate the business of insurance."

The Bailey decision joins several recent rulings that enforce the preemptive effective of the ADA on state statutory and common law challenges to air ambulance operators' prices and services.10 It further underscores the reality that an air ambulance operator often has an obligation to provide emergency transport irrespective of the passenger's insurance coverage or ability to pay for such services.


1 The author, along with Phil Rothschild, represented the air ambulance operator in the appellate and trial courts. She also argued the appeal.

2 __ F.3d __, 2018 WL 2107176 (11th Cir. May 8, 2018).

3 49 U.S.C. § 41713(b)(1).

4 Fla. Stat. § 627.736. The PIP statute is part of Florida's Motor Vehicle No-Fault Law, Fla. Stat. § 627.730, et. seq.

5 The parties disputed the meaning of this language in the PIP statute, with the operator contending that it permits the medical provider to balance bill. The panel recognized that the Florida Supreme Court has not yet opined on this issue; however, by finding preemption, the Eleventh Circuit did not definitively rule on the plain meaning of the statute.

6 See Bailey v. Rocky Mountain Holdings LLC, No. 13-62447 (S.D. Fla. Sept. 23, 2015), and HK Aviation Law Blog, Oct. 6, 2015. In a prior opinion, the court denied class certification, finding that individualized issues predominated over common ones in the proposed classes. See Bailey v. Rocky Mountain Holdings, LLC, No. 13-62447 (S.D. Fla. Aug. 10, 2015). Although plaintiff appealed the class certification decision, the finding of express preemption made it unnecessary to decide that issue.

7 Quoting Am. Airlines, Inc. v. Wolens, 513 U.S. 219, 222.

8 Citing Blackfeet Nat'l Bank v. Nelson, 171 F.3d 1237, 1244 (11th Cir. 1999).

9 Quoting Union Labor Life Ins. Co. v. Pireno, 458 U.S. 119, 129 (1982).

10 See, e.g., EagleMed LLC v. Cox, 868 F.3d 893 (10th Cir. 2017); Stout v. Med-Trans Corp., No. 1:17-cv-115-MW/GRJ (N.D. Fla. May 2, 2018); Schneberger v. Air Evac EMS, Inc., No. CIV-16-843-R, 2017 WL 1026012 (W.D. Okla. Mar. 15, 2017); Valley Med Flight, Inc. v. Dwelle, 171 F. Supp. 3d 930 (D.N.D. 2016).

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

Similar Articles
Relevancy Powered by MondaqAI
In association with
Related Topics
Similar Articles
Relevancy Powered by MondaqAI
Related Articles
Up-coming Events Search
Font Size:
Mondaq on Twitter
Mondaq Sign Up
Gain free access to lawyers expertise from more than 250 countries.
Email Address
Company Name
Confirm Password
Mondaq Newsalert
Select Topics
Select Regions
Registration (you must scroll down to set your data preferences)

Mondaq Ltd requires you to register and provide information that personally identifies you, including your content preferences, for three primary purposes (full details of Mondaq’s use of your personal data can be found in our Privacy and Cookies Notice):

  • To allow you to personalize the Mondaq websites you are visiting to show content ("Content") relevant to your interests.
  • To enable features such as password reminder, news alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our content providers ("Contributors") who contribute Content for free for your use.

Mondaq hopes that our registered users will support us in maintaining our free to view business model by consenting to our use of your personal data as described below.

Mondaq has a "free to view" business model. Our services are paid for by Contributors in exchange for Mondaq providing them with access to information about who accesses their content. Once personal data is transferred to our Contributors they become a data controller of this personal data. They use it to measure the response that their articles are receiving, as a form of market research. They may also use it to provide Mondaq users with information about their products and services.

Details of each Contributor to which your personal data will be transferred is clearly stated within the Content that you access. For full details of how this Contributor will use your personal data, you should review the Contributor’s own Privacy Notice.

Please indicate your preference below:

Yes, I am happy to support Mondaq in maintaining its free to view business model by agreeing to allow Mondaq to share my personal data with Contributors whose Content I access
No, I do not want Mondaq to share my personal data with Contributors

Also please let us know whether you are happy to receive communications promoting products and services offered by Mondaq:

Yes, I am happy to received promotional communications from Mondaq
No, please do not send me promotional communications from Mondaq
Terms & Conditions

Mondaq.com (the Website) is owned and managed by Mondaq Ltd (Mondaq). Mondaq grants you a non-exclusive, revocable licence to access the Website and associated services, such as the Mondaq News Alerts (Services), subject to and in consideration of your compliance with the following terms and conditions of use (Terms). Your use of the Website and/or Services constitutes your agreement to the Terms. Mondaq may terminate your use of the Website and Services if you are in breach of these Terms or if Mondaq decides to terminate the licence granted hereunder for any reason whatsoever.

Use of www.mondaq.com

To Use Mondaq.com you must be: eighteen (18) years old or over; legally capable of entering into binding contracts; and not in any way prohibited by the applicable law to enter into these Terms in the jurisdiction which you are currently located.

You may use the Website as an unregistered user, however, you are required to register as a user if you wish to read the full text of the Content or to receive the Services.

You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these Terms or with the prior written consent of Mondaq. You may not use electronic or other means to extract details or information from the Content. Nor shall you extract information about users or Contributors in order to offer them any services or products.

In your use of the Website and/or Services you shall: comply with all applicable laws, regulations, directives and legislations which apply to your Use of the Website and/or Services in whatever country you are physically located including without limitation any and all consumer law, export control laws and regulations; provide to us true, correct and accurate information and promptly inform us in the event that any information that you have provided to us changes or becomes inaccurate; notify Mondaq immediately of any circumstances where you have reason to believe that any Intellectual Property Rights or any other rights of any third party may have been infringed; co-operate with reasonable security or other checks or requests for information made by Mondaq from time to time; and at all times be fully liable for the breach of any of these Terms by a third party using your login details to access the Website and/or Services

however, you shall not: do anything likely to impair, interfere with or damage or cause harm or distress to any persons, or the network; do anything that will infringe any Intellectual Property Rights or other rights of Mondaq or any third party; or use the Website, Services and/or Content otherwise than in accordance with these Terms; use any trade marks or service marks of Mondaq or the Contributors, or do anything which may be seen to take unfair advantage of the reputation and goodwill of Mondaq or the Contributors, or the Website, Services and/or Content.

Mondaq reserves the right, in its sole discretion, to take any action that it deems necessary and appropriate in the event it considers that there is a breach or threatened breach of the Terms.

Mondaq’s Rights and Obligations

Unless otherwise expressly set out to the contrary, nothing in these Terms shall serve to transfer from Mondaq to you, any Intellectual Property Rights owned by and/or licensed to Mondaq and all rights, title and interest in and to such Intellectual Property Rights will remain exclusively with Mondaq and/or its licensors.

Mondaq shall use its reasonable endeavours to make the Website and Services available to you at all times, but we cannot guarantee an uninterrupted and fault free service.

Mondaq reserves the right to make changes to the services and/or the Website or part thereof, from time to time, and we may add, remove, modify and/or vary any elements of features and functionalities of the Website or the services.

Mondaq also reserves the right from time to time to monitor your Use of the Website and/or services.


The Content is general information only. It is not intended to constitute legal advice or seek to be the complete and comprehensive statement of the law, nor is it intended to address your specific requirements or provide advice on which reliance should be placed. Mondaq and/or its Contributors and other suppliers make no representations about the suitability of the information contained in the Content for any purpose. All Content provided "as is" without warranty of any kind. Mondaq and/or its Contributors and other suppliers hereby exclude and disclaim all representations, warranties or guarantees with regard to the Content, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. To the maximum extent permitted by law, Mondaq expressly excludes all representations, warranties, obligations, and liabilities arising out of or in connection with all Content. In no event shall Mondaq and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use of the Content or performance of Mondaq’s Services.


Mondaq may alter or amend these Terms by amending them on the Website. By continuing to Use the Services and/or the Website after such amendment, you will be deemed to have accepted any amendment to these Terms.

These Terms shall be governed by and construed in accordance with the laws of England and Wales and you irrevocably submit to the exclusive jurisdiction of the courts of England and Wales to settle any dispute which may arise out of or in connection with these Terms. If you live outside the United Kingdom, English law shall apply only to the extent that English law shall not deprive you of any legal protection accorded in accordance with the law of the place where you are habitually resident ("Local Law"). In the event English law deprives you of any legal protection which is accorded to you under Local Law, then these terms shall be governed by Local Law and any dispute or claim arising out of or in connection with these Terms shall be subject to the non-exclusive jurisdiction of the courts where you are habitually resident.

You may print and keep a copy of these Terms, which form the entire agreement between you and Mondaq and supersede any other communications or advertising in respect of the Service and/or the Website.

No delay in exercising or non-exercise by you and/or Mondaq of any of its rights under or in connection with these Terms shall operate as a waiver or release of each of your or Mondaq’s right. Rather, any such waiver or release must be specifically granted in writing signed by the party granting it.

If any part of these Terms is held unenforceable, that part shall be enforced to the maximum extent permissible so as to give effect to the intent of the parties, and the Terms shall continue in full force and effect.

Mondaq shall not incur any liability to you on account of any loss or damage resulting from any delay or failure to perform all or any part of these Terms if such delay or failure is caused, in whole or in part, by events, occurrences, or causes beyond the control of Mondaq. Such events, occurrences or causes will include, without limitation, acts of God, strikes, lockouts, server and network failure, riots, acts of war, earthquakes, fire and explosions.

By clicking Register you state you have read and agree to our Terms and Conditions