United States District Court, D. New Jersey
SPINE SURGERY ASSOCIATES & DISCOVERY IMAGING, PC on assignment of ANTHONY P., Plaintiff,
INDECS CORP. and CONSTANT SERVICES INC., Defendants
For SPINE SURGERY ASSOCIATES & DISCOVERY IMAGING, P.C., Plaintiff: SEAN R. CALLAGY, LEAD ATTORNEY, LAW OFFICE OF SEAN R. CALLAGY, ESQ., MACK-CALI CENTRE II, PARAMUS, NJ.
For INDECS CORP-CONSTANT SERVICES INC., Defendant: ANDREW SETH BERNS, LEAD ATTORNEY, EINHORN, HARRIS, ASCHER, BARBARITO, FROST & IRONSON, PC, DENVILLE, NJ; SEAN X. KELLY, SEAN ROBINS, LEAD ATTORNEYS, MARKS, O'NEILL, O'BRIEN, DOHERTY & KELLY, PC, PENNSAUKEN, NJ.
For Constant Services Inc., Defendant: ANDREW S. BERNS, LEAD ATTORNEY, EINHORN, HARRIS, ASCHER, BARBARITO & FROST, DENVILLE, NJ.
Katharine S. Hayden, United States District Judge.
A medical practice that performed two spinal surgical procedures has sued the sponsor of its patient's benefit plan and the plan's claims administrator for unreimbursed charges that amount to over $80,000. At issue in the motion before the Court is whether the provider, as opposed to the subscriber, has the right to bring claims under the Employee Retirement Income Security Act (" ERISA," 29 U.S.C. § 1001 et seq.).
In its four-count amended complaint [D.E. 19], plaintiff Spine Surgery Associates & Discovery Imaging (" Spine Surgery" ) brought ERISA claims, as well as a common-law breach of contract claim, against defendants INDECS Corp. (" INDECS" ) and Constant Services, Inc. (" Constant" ). INDECS now moves to dismiss [D.E. 20] pursuant to Fed.R.Civ.P. 12(b)(6), arguing that as plan administrator it is not a proper defendant and that Spine Surgery is not a proper plaintiff. For the following reasons, the motion will be granted in part and denied in part.
The facts are taken from the amended complaint and the attached exhibits. In ruling on a motion to dismiss, the Court accepts as true all well-pleaded factual allegations in the complaint and draws all reasonable inferences in the plaintiff's favor, granting dismissal only if the pleading does not suggest a plausible entitlement to relief. Huertas v. Galaxy Asset Mgmt., 641 F.3d 28, 32 (3d Cir. 2011) (per curiam).
Spine Surgery is a healthcare provider in Somerset and, on two occasions in 2012, provided medical and surgical care to non-party Anthony P. (Am. Compl. ¶ 1.) At the time of these procedures, Anthony P. was enrolled in an Employee Benefit Plan that was sponsored by Constant. The total cost of Anthony P's procedures was $119,314 and Spine Surgery submitted bills to INDECS, as claims administrator, for that amount. After receiving payment
for only $37,977.93 of the amount billed, Spine Surgery commenced this action.
A) The Employee Benefit Plan
Constant's Employee Benefit Plan (the " Plan" ), adopted in October 2011, is an ERISA welfare plan (as defined by 29 U.S.C. § 1002(1)) providing Anthony P. with health care benefits. (Am. Compl. ¶ 2.) The " Plan Document and Summary Plan Description" is attached to the amended complaint as Exhibit A. Constant is the Plan's administrator, with responsibilities that include interpreting the Plan with " maximum legal discretionary authority," keeping and maintaining documents associated with the Plan, and appointing a separate claims administrator to pay claims. (Plan Document 50.) That claims administrator is INDECS, the moving defendant. (Plan Document 59.)
The Plan follows what is often called the preferred provider organization (PPO) model. Under it, certain medical providers, such as hospitals and physicians who are termed " Network Providers," have agreed to charge reduced fees to members of the Plan, thereby enabling the Plan to reimburse higher percentages of costs charged by those providers. (Plan Document 10-12.) The Plan requires precertification for certain treatment options and surgical procedures. (Plan Document 20-21.)
In order to pursue a claim for benefits, a covered person--that is, an employee or dependent (Plan Document 23)--must submit a completed claim form to INDECS with bills attached for services rendered. Claims must generally be filed within 45 days after charges are incurred. If INDECS denies the claim, it provides the covered person with written notice. A covered person wishing to challenge a whole or partial denial can appeal by directing a request for review to either INDECS or Constant as the Plan Administrator. (Plan Document 34-35.)
Plan materials also explain the ERISA rights that participants and covered persons have under the Plan. Among other things, the discussion of rights covers the ability to sue in certain contexts to enforce Plan rights and fiduciary obligations. ( See Plan Document 51-52.)
The relationship between INDECS and Constant is set out in a separate Administrative Services Agreement (the " Agreement" ), attached to the amended complaint as Exhibit B. The Agreement originally was executed by INDECS's predecessor; INDECS was assigned responsibility on January 1, 2011. In part, the Agreement builds on the statement in the Plan that INDECS is not a Plan fiduciary. (Plan Document 51.) Rather, as claims administrator, INDECS acts as Constant's agent, and is specifically required to consult with Constant about any " claim matters that are beyond the ordinary." (Agreement 1-3.) INDECS's main role is to " adjudicate claims on behalf of and under the direction and authority of" Constant, and to " perform such other services as may be required in connection with claims administration." (Agreement 4.) An appendix defines a variety of basic services under the Agreement.
B) Surgery and Benefits Assignment
Anthony P. is a covered person under the Plan. (Am. Compl. ¶ ¶ 2, 6.) Twice in 2012, in January and in May, he received care from Spine Surgery. (Am. Compl. ¶ 1.) (The exact procedures are set forth in the medical records attached to the complaint as Exhibit C.)
Shortly before undergoing the first procedure, Anthony P. executed what the amended complaint calls an " assignment of benefits" (Am. Compl. ¶ 8), which is attached
as Exhibit D. The document is titled " Patient Registration: Office Policy/Assignment of Insurance Benefits -- Authorization to Release Information" (the " Assignment" ) and provides in relevant part:
In consideration of services rendered or to be rendered to the above named patient, I hereby authorize payment directly to Spine Surgery Associates & Discovery Imaging, PC. or other provider of health services of any and all insurance benefits to which I may otherwise be entitled for services rendered by the provider, but not to exceed the provider's standard charges for such services.
In the event the provider's charges are outstanding, I hereby authorize the provider to file such claim with my insurance company on my behalf so that the provider may realize payment of its charges. I understand that Spine Surgery . . . is not a participating provider with my insurance company and that I am responsible for paying all applicable co-payments, co-insurance, deductibles and amounts determined above the allowed as determined by my insurance policy, State laws and regulations. I also agree that if the provider does not receive full payment from my insurance company on a timely basis, I am personally responsible for full payment of the provider's standard charges. . . . I authorize the release of any medical and other information necessary to process insurance claims.
C) Spine Surgery Submits Claim for ...