Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Montvale Surgical Center, LLC v. Aetna Insurance Co.

United States District Court, Third Circuit

May 22, 2013

MONTVALE SURGICAL CENTER, LLC a/s/o THOMAS S., Plaintiff,
v.
AETNA INSURANCE COMPANY; ABC CORP. (1-10)(Said names being fictitious and unknown entities, Defendants.

OPINION

SUSAN D. WIGENTON, District Judge.

Before this Court is Defendant Aetna Health Inc.'s motion for summary judgment pursuant to Federal Rule of Civil Procedure 56. This Court, having considered the parties' submissions, decides this matter without oral argument pursuant to Federal Rule of Civil Procedure 78. For the reasons stated below, Defendant's motion is GRANTED. Defendant's request for attorney's fees and costs of suit is DENIED.

I. FACTUAL AND PROCEDURAL BACKGROUND

Montvale Surgical Center, LLC ("MSC") is "an outpatient Ambulatory Surgical Center (ASC) where minimally invasive pain management and podiatry procedures are performed, having its office located at 6 Chestnut Ridge Road, Montvale, NJ[.]" (Notice of Removal, Ex. A ¶ 1.) "At all relevant times, [MSC] was an out of network' medical practice." ( Id. ) Aetna Health Inc. ("Aetna"), improperly pled as Aetna Insurance Company, as it pertains to this case, "served as [a] benefit provider of the group health benefit plan [for] Belle Associates, LLC." (Answer ¶ 3.) Aetna contracted with Belle Associates, LLC, the employer of subrogor Thomas S., to provide healthcare benefits pursuant to the terms of a Small Group Health Maintenance Organization ("HMO") Point of Service ("POS") plan ("Plan") governed by the Employee Retirement Income Security Act of 1974, codified in 29 U.S.C. § 1001 et seq. (Certification of Michael C. McNamara ("McNamara Cert."), Ex. A.)

The Plan

The Plan states that "a claim occurs whenever a Member or a Member's authorized representative, such as a Provider... requests payment for services or treatments received." (McNamara Cert. Ex. A, at 32.) The Plan also establishes that when a claim is submitted, "[Aetna] will make a decision [regarding] the Member's claim." ( Id. ) The Plan defines discretion/determination/determine as "[Aetna's] sole right to make a decision or determination." ( Id. at 13.) The Plan defines "Covered Charges" as

Reasonable and Customary charges for the types of services and supplies described in the Covered Charges and Covered Charges with Special Limitations section of the [Plan], as applicable to Non-Network benefits. The services and supplies must be: (a) furnished or ordered by a health care Provider; and (b) Medically Necessary and Appropriate to diagnose or treat an Illness or Injury.

( Id. at 11.) The Plan describes medically necessary and appropriate treatment as services Aetna deems to be:

a) necessary for symptoms and diagnosis or treatment of the condition, Illness or Injury;
b) provided for the diagnosis or the direct care and treatment of the condition, Illness or Injury;
c) in accordance with generally accepted medical practice;
d) not for a Member's convenience;
e) the most appropriate level of medical care that a Member needs; and
f) furnished within the framework of generally accepted methods of medical management currently used in the United States.

( Id. at 16-17.) The Plan distinguishes between "Non-Covered Services and Supplies and Non-Covered Charges" stating:

THE FOLLOWING ARE NOT COVERED SERVICES AND SUPPLIES WITH RESPECT TO NETWORK SERVICES AND SUPPLIES, AND ARE NOT COVERED CHARGES WITH RESPECT TO NON -NETWORK BENEFITS UNDER THE CONTRACT
...
Experimental or Investigational treatments, procedures, hospitalization, drugs, biological products or medical devices, except as otherwise stated in the [Plan].

( Id. at 61.) The Plan defines experimental and investigational services as those

a) not of proven benefit for the particular diagnosis or treatment of the Member's particular condition; or
b) not generally recognized by the medical community as effective or appropriate for the particular diagnosis or treatment of a members [sic] particular condition; or
c) provided or performed in special settings for research purposes or under a controlled ...

Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.