United States District Court, D. New Jersey
JASON D. COHEN, MD, FACS and PROFESSIONAL ORTHOPAEDIC ASSOCIATES, PA AS ASSIGNEE AND DESIGNATED AUTHORIZED REPRESENTATIVE OF PATIENT JE, and PATIENT JE, Plaintiffs,
HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY. Defendants
Katharine S. Hayden, U.S.D.J.
matter comes before the Court upon a motion (D.E. 32) filed
by plaintiffs to remand this case to New Jersey state court
on the ground that plaintiffs' claims are not preempted
by the Employee Retirement Income Security Act of 1974
(“ERISA”). For the reasons set forth below,
plaintiffs' motion is denied.
about May 15, 2015, plaintiffs filed a complaint in New
Jersey state court seeking to recover benefits allegedly due
for emergency medical services rendered to patient JE by
Jason Cohen, a shareholder of Professional Orthopaedic
Associates, PA (“POA”). Horizon Blue Cross Blue
Shield of New Jersey (“Horizon”) first received a
copy of the complaint on May 27, 2015 and filed a timely
notice of removal on June 26, 2015, pursuant to 28 U.S.C.
§ 1331 and § 1441(a) and (c), based on the position
that plaintiffs “seek to recover benefits from Horizon
under the terms of an employee benefit plan governed by ERISA
and bring claims for benefits within Section 502(a) of
ERISA, 29 U.S.C. § 1132(a), over which this court has
federal question jurisdiction pursuant to 28 U.S.C. §
1131.” Plaintiffs filed an amended complaint
(hereinafter, the “complaint”) on December 7,
2015 (D.E. 19).
to the complaint, Horizon is the plan administrator for
JE's employer provided health insurance plan. (Compl.,
¶ 4.) On or about January 6, 2014, Cohen and POA sought
payment from Horizon by filing a claim for emergency surgery
and procedures Cohen performed on JE. (Compl., ¶ 18.)
The services provided were “out-of-network, ”
meaning that Cohen and POA did not have a contract with
Horizon to accept any agreed upon rates. (Compl.,
¶¶ 20-21.) With respect to out-of-network services,
JE signed certain agreements with Cohen and POA making him
personally responsible for all medical charges and assigning
all rights and benefits due from Horizon to them, including
standing to appeal and/or sue on the basis of Horizon's
claim payment decisions. (Compl., ¶¶ 13-17.)
about March 13, 2014, Horizon made a single payment of $100,
507.58 on a claim that Cohen submitted for the
above-referenced medical services. (Compl., ¶ 25.) On
July 31, 2014, Horizon sent a refund request for $97, 820.00,
stating that it had overpaid for the services rendered to JE.
(Compl., ¶ 26.) After denying an appeal by Cohen and
POA, and in satisfaction of its refund request, Horizon
allegedly “took back” $97, 820.06 from claims
being paid to Cohen by Horizon on behalf of 30 different
patients it insured. (Compl., ¶ 31.) Cohen and POA then
filed another appeal which was also denied, giving rise to
the instant action.
complaint pleads violations of N.J.A.C. 11:24-5.3
(“Emergency and urgent care services”) and the
New Jersey Healthcare Information and Technologies Act
(“HINT”), in addition to a common law cause of
action for unjust enrichment. Plaintiffs' motion to
remand to state court on the basis that ERISA does not
preempt claims for payment under N.J.A.C. 11:24-5.3 and HINT
has been fully briefed (D.E. 32, 39, 40).
Court makes its decision on the papers.
Standard of Review
civil action brought in state court may be removed by the
defendant to the federal district court in the district where
such action is pending, if the district court would have
original jurisdiction over the matter.” U.S.
Express Lines Ltd. v. Higgins, 281 F.3d 383, 389 (3d
Cir. 2002) (citing 28 U.S.C. § 1441(a)). Thus, removal
is not appropriate if the case does not fall within the
district court's original federal question jurisdiction
and the parties are not diverse. Id. The party
asserting jurisdiction bears the burden of showing that at
all stages of the litigation the case is properly before the
federal court. Samuel-Bassett v. KIA Motors Am.,
Inc., 357 F.3d 392, 396 (3d Cir. 2004).
the well-pleaded complaint rule, a cause of action
‘arises under' federal law, and removal is proper,
only if a federal question is presented on the face of the
plaintiff's properly pleaded complaint.” Dukes
v. U.S. Healthcare, Inc., 57 F.3d 350, 353 (3d Cir.
1995). However, the Supreme Court has recognized an exception
to the well-pleaded complaint rule. Id.
“Congress may so completely pre-empt a particular area
that any civil complaint raising this select group of claims
is necessarily federal in character.” Metro. Life
Ins. Co. v. Taylor, 481 U.S. 58, 63 (1987).
argue that remand is proper because their state law claims
under N.J.A.C. 11:24-5.3 and HINT create legal obligations
that are independent of the terms of an ERISA plan and thus
do not fall within the scope of ERISA's preemption
clause. ERISA contains a preemption clause providing that the
act “shall supersede any and all state laws insofar as
they may now or hereafter relate to any employee benefit
plan.” 29 U.S.C. § 1144(a) (emphasis added). The
Supreme Court has noted the “expansive sweep of the
preemption clause[, ]” see Pilot Life Ins. Co. v.
Dedeaux, 481 U.S. 41, 47 (1987), and, in a recent
decision, elaborated on the current state of the ERISA
First, ERISA pre-empts a state law if it has a
‘reference to' ERISA plans. To be more precise,
where a State's law acts immediately and exclusively upon
ERISA plans . . . or where the existence of ERISA plans is
essential to the law's operation . . ., that
‘reference' will result in pre-emption. Second,
ERISA pre-empts a state law that has an impermissible
‘connection with' ERISA plans, meaning a state law
that governs . . . a central matter of plan administration or
interferes with nationally uniform plan administration. A
state law also might have an impermissible connection with
ERISA plans if ‘acute, albeit indirect, economic
effects' of the state law ‘force an ERISA plan to
adopt a certain scheme of ...