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Atlantic Spinal Care v. Highmark Blue Shield

United States District Court, Third Circuit

July 1, 2013

ATLANTIC SPINAL CARE, Plaintiff,
v.
HIGHMARK BLUE SHIELD, et al., Defendants.

OPINION

JOSE L. LINARES, District Judge.

This matter comes before the Court by way of Defendant Highmark Blue Shield's motion to dismiss Plaintiff's Complaint for lack of standing pursuant to Federal Rule of Civil Procedure 12(b)(1) [Docket Entry No. 9], and Plaintiff's cross-motion to amend the Complaint [Docket Entry No. 10]. The Court has considered the submissions made in support of and in opposition to the instant motions. No oral argument was heard. See Fed.R.Civ.P. 78. For the reasons that follow, Defendant's motion to dismiss is granted, as is Plaintiff's motion to amend. Plaintiff's Complaint is dismissed without prejudice. Plaintiff may file an Amended Complaint on or before August 23, 2013.

BACKGROUND[1]

This lawsuit arises out of a dispute between a healthcare provider and an insurance company over an alleged disclosure violation. In March 2013, Plaintiff, Atlantic Spinal Care- the healthcare provider-filed a Complaint against Highmark Blue Shield-the insurance company-seeking relief from an alleged disclosure violation pursuant to Section 502(a)(1)(A) of ERISA, codified at 29 U.S.C. § 1132(a)(1)(A). Plaintiff's Complaint was originally filed in the Superior Court of New Jersey, Law Division, Middlesex County, in or around March 2013. Defendant removed the matter to federal court in May 2013 pursuant to 28 U.S.C. § 1441. This Court's jurisdiction over Plaintiff's Complaint is premised on 28 U.S.C. § 1331.

Plaintiff's Complaint alleges that at some point in 2010, Plaintiff provided medically reasonable services to "Donald L." (Compl., ¶ 4). The Complaint further alleges that Plaintiff had obtained an assignment of benefits from Donald L. regarding the health benefits at issue- which, according to Plaintiff, are subject to ERISA because the benefits were obtained through participation in an employee benefit plan. (Compl., ¶¶ 5, 9). After providing such medical services, Plaintiff prepared and submitted to Defendant a Health Care Insurance Claim Form, demanding reimbursement in the amount of $66, 800.00. (Compl., ¶ 6). Plaintiff subsequently received payment issued by Defendant in the amount of $6, 594.49. (Compl., ¶ 7). Thereafter, it is alleged that Plaintiff engaged in the applicable administrative appeals process maintained by Defendant. (Compl., ¶ 8).

In light of the foregoing, Plaintiff brings a single claim pursuant to Section 502(a)(1)(A) of ERISA based on Defendant's alleged: (1) failure to issue an Adverse Benefit Determination in accordance with the requirements of ERISA, and (2) failure to comply with Plaintiff's request for information and documents including but not limited to the "Summary Plan Document." (Compl., ¶¶ 10-14). The Complaint further alleges that Plaintiff has been prejudiced by Defendant's alleged disclosure violation(s) because it has not been able to identify the Plan Sponsor or to assess the application of the terms of the Summary Plan Document prior to asserting a claim for benefits under ERISA § 502(a)(1)(B).

On June 7, 2013, Defendant filed a motion to dismiss the Complaint pursuant to Rule 12(b)(1) on the basis that Plaintiff lacks standing to assert an ERISA claim inasmuch as it is neither a plan participant nor a beneficiary under the plan.

LEGAL STANDARD

Pursuant to Rule 12(b)(1), the court must dismiss a complaint if it lacks subject matter jurisdiction to hear a claim. Fed.R.Civ.P. 12(b)(1). Standing is a jurisdictional matter and thus "a motion to dismiss for want of standing is also properly brought pursuant to Rule 12(b)(1)." Ballentine v. United States, 486 F.3d 806, 810 (3d Cir. 2007). As per Rule 12(b)(1), the court must accept as true all material allegations set forth in the complaint, and must construe those facts in favor of the nonmoving party. Id.

Motions to dismiss under Rule 12(b)(1) may be treated as either a "facial or factual challenge to the court's subject matter jurisdiction." Gould Elecs. Inc. v. United Stat es, 220 F.3d 169, 176 (3d Cir. 2000). Under a facial attack, the movant challenges the legal sufficiency of the claim and the Court considers only "the allegations of the complaint and documents referenced therein and attached thereto in the light most favorable to the plaintiff." Id. In reviewing a factual attack, however, the challenge is to the actual alleged jurisdictional facts. Id. at 176-77. Thus, in that instance a court is free to consider evidence outside of the pleadings. Id.

DISCUSSION

As previously stated, Defendant seeks dismissal of Plaintiff's Complaint on the basis that Plaintiff lacks standing to assert an ERISA claim inasmuch as it is neither a plan participant nor a beneficiary under the plan. Moreover, Defendant maintains that any purported assignment of rights from Donald L.-the plan participant-to Plaintiff is void because the applicable health benefits plan contains a clear anti-assignment provision that expressly prohibits Donald L. from assigning his rights and/or benefits to anyone. Because Defendant challenges the facts underlying Plaintiff's jurisdictional assertions, the Court may consider evidence outside the pleadings. See Gould, 220 F.3d at 176.

1. Standing

Pursuant to § 502(a) of ERISA, "a participant or beneficiary" may bring a civil action to, inter alia, "recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan." 29 U.S.C. § 1132(a). It is clear, therefore, that standing to sue under the statute is "limited to participants and beneficiaries." Pascack Valley Hosp. v. Local 464A UFCW Welfare Reimbursement Plan, 388 F.3d 393, 400-401 (3d Cir. 2004). If Plaintiff has no ...


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