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Cohen v. Horizon Blue Cross Blue Shield of New Jersey

United States District Court, D. New Jersey

January 21, 2014

DR. JASON D. COHEN, M.D., F.A.C.S., as designated representative of F.L., and Patient F.L., Plaintiffs,
v.
HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY and VISITING NURSE ASSOCIATION HEALTH GROUP Defendants.

OPINION

JOSE L. LINARES, District Judge.

This matter comes before the Court by way of Defendant Horizon Blue Cross Blue Shield of New Jersey ("Horizon")'s motion to dismiss Plaintiffs' Amended Complaint pursuant to Federal Rules of Civil Procedure 12(b)(6) and 12(b)(1). The Court has considered the submissions made in support of and in opposition to Horizon's motion, and decides this matter without oral argument pursuant to Federal Rule of Civil Procedure 78. For the reasons set forth below, Horizon's motion is granted. Plaintiff's Amended Complaint is dismissed in its entirety without prejudice.

I. BACKGROUND

On October 25, 2013, this Court entered an Opinion an Order granting in part and denying in part Defendant's motion to dismiss Plaintiff's original complaint. This Court's October 25, 2013 Opinion contained a detailed discussion of the facts alleged in Plaintiff's original complaint. Because Defendant agrees that the crux of the facts alleged in the Amended Complaint are the same as those alleged in the original complaint, the Court hereby incorporates its thorough discussion of the relevant facts contained in its October 25, 2013 Opinion and will repeat only those facts that are pertinent to the instant motion.

Plaintiffs Dr. Jason Cohen ("Dr. Cohen") and Patient F.L. bring this action under the Employee Retirement Income Security Act ("ERISA") to recover alleged underpayments for two medical procedures Dr. Cohen performed on Patient F.L. in 2011. This Court's jurisdiction is premised on 28 U.S.C. § 1331.

At the time of the medical procedures at issue, Patient F.L. was a participant in a health plan (the "Plan") self-insured by his employer, Defendant Visiting Nurse Association Health Group ("VNA"). VNA served as the Plan's administrator, and was responsible for making all final decisions with respect to claims brought under the Plan. Horizon served as the Plan's third-party administrator, and was responsible for the initial review of claims, and providing administrative services.

When providing services as an out-of-network provider, Dr. Cohen requires all patients to sign documents whereby the patient agrees to be personally liable for all medical charges. Dr. Cohen also obtains from the patient an Authorization of Designated Representative and an Assignment of Benefits with Rights ("AOB") which allegedly make Dr. Cohen a beneficiary under the Plan. Dr. Cohen does not waive any deductible or co-payment by accepting the AOB.

Dr. Cohen performed two separate medical procedures that are the subject of Plaintiffs' claims. As to the first medical procedure, on or about May 16, 2011, Dr. Cohen sought payment from Horizon by filing an electronic claim seeking $221, 847.00. On or about July 1, 2011, Horizon allegedly made a single payment to Patient F.L. in the amount of $42, 557.38, which Patient F.L. surrendered to Dr. Cohen in accordance with the AOB. Plaintiffs claim that this payment was $179, 289.62 less than the amount of the claim, and represented less than 20% of the amount of the billed services.

At some point toward the end of 2011, Dr. Cohen performed a second medical procedure on Patient F.L. On or about December 2, 2011, Dr. Cohen sought payment from Horizon by filing an electronic claim seeking $84, 212.00 for the second procedure performed on Patient F.L. Horizon subsequently made a single payment to Patient F.L. in the amount of $4, 320.00, which Patient F.L. surrendered to Dr. Cohen in accordance with the AOB. This payment was $79, 892.00 less than the claim Dr. Cohen submitted, and represented approximately 5% of the total amount of the services billed. Plaintiffs appealed both determinations; on December 5, 2012, Patient F.L. received a written denial stating that he has "now exhausted all the appeal rights through Horizon" and forwarded this letter to Dr. Cohen.

Plaintiff's Amended Complaint contains a single claim of violation of ERISA, § 502(a) as against both Defendants-VNA, the Plan's administrator, and Horizon, the Plan's third-party administrator. Plaintiffs seek, inter alia, payment of benefits allegedly due under the Plan.

Defendant Horizon has filed a motion to dismiss Plaintiff's Amended Complaint on two overarching grounds: (1) Dr. Cohen lacks standing to pursue a claim for benefits on behalf of Patient F.L., and (2) the Amended Complaint fails to state a facially plausible claim against Horizon because, as a third-party administrator, it cannot be held liable for benefits under the Plan.

II. LEGAL STANDARD

A. Federal Rule of Civil Procedure 12(b)(1)

"Federal Rule of Civil Procedure 12(b)(1) provides that a party may bring a motion to dismiss for lack of subject matter jurisdiction." Ballentine v. United States, 486 F.3d 806, 810 (3d Cir. 2007). "A motion to dismiss for want of standing is also properly brought pursuant to Rule 12(b)(1), because standing is a jurisdictional matter." Id. "The party invoking federal jurisdiction bears the burden of establishing the elements of standing, and each element must be supported in the same way as any other matter in which the plaintiff bears the burden of proof, i.e., with the manner and degree of evidence required at the successive stages of the ...


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