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Shah v. Horizon Blue Cross Blue Shield of New Jersey

United States District Court, D. New Jersey

May 4, 2017

RAHUL SHAH, M.D., assignee of Monica M., Plaintiff,
v.
HORIZON BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, Defendant.

          CALLAGY LAW, P.C. By: Michael Gottlieb, Esq. Counsel for Plaintiff.

          BECKER LLC Michael E. Holzapfel, Esq. Counsel for Defendant Horizon Blue Cross Blue Shield of Massachusetts.

          OPINION

          HILLMAN, United States District Judge.

         This is one of many ERISA suits[1] filed by Plaintiff Dr. Rahul Shah, as purported assignee of his individual patients, against his patients' various insurance companies. In each suit, Dr. Shah asserts that the insurance companies wrongfully denied requests for payment of benefits under the patients' health insurance policies, and consequently, Dr. Shah's bills for services were not paid, or not fully paid.

         Presently before the Court is Defendant's Motion to Dismiss the Complaint pursuant to Fed.R.Civ.P. 12(b)(6). For the reasons stated herein, the motion will be granted in part, denied in part, and denied as moot in part.

         I.

         On October 28, 2013, Dr. Shah allegedly performed surgery on Monica M. (Compl. ¶ 5-6; and Ex. A) He alleges all services were medically necessary and reasonable (Id. at ¶ 5), yet Monica M.'s health insurance company, Defendant Horizon Blue Cross Blue Shield of Massachusetts, allegedly denied the claim. (Compl. ¶ 8)

         Dr. Shah alleges that he obtained an assignment of benefits from Monica M. (Compl. ¶ 7 and Ex. B) The Complaint asserts four claims: breach of contract; denial of benefits in violation of § 1132(a)(1)(B); breach of fiduciary duty in violation of § 1132(a)(3)(B); and failure to maintain a reasonable claims process pursuant to 29 C.F.R. 2560.503-1.

         II.

         When considering a motion to dismiss a complaint for failure to state a claim upon which relief can be granted pursuant to Federal Rule of Civil Procedure 12(b)(6), a court must accept all well-pleaded allegations in the complaint as true and view them in the light most favorable to the plaintiff. Evancho v. Fisher, 423 F.3d 347, 351 (3d Cir. 2005). It is well settled that a pleading is sufficient if it contains “a short and plain statement of the claim showing that the pleader is entitled to relief.” Fed.R.Civ.P. 8(a)(2).

         Under the liberal federal pleading rules, it is not necessary to plead evidence, and it is not necessary to plead all the facts that serve as a basis for the claim. Bogosian v. Gulf Oil Corp., 562 F.2d 434, 446 (3d Cir. 1977). However, “the Federal Rules of Civil Procedure . . . do require that the pleadings give defendant fair notice of what the plaintiff's claim is and the grounds upon which it rests.” Baldwin Cnty. Welcome Ctr. v. Brown, 466 U.S. 147, 149-50 n.3 (1984) (quotation and citation omitted).

         A district court, in weighing a motion to dismiss, asks “‘not whether a plaintiff will ultimately prevail but whether the claimant is entitled to offer evidence to support the claim.'” Bell Atlantic v. Twombly, 550 U.S. 544, 563 n.8 (2007) (quoting Scheuer v. Rhoades, 416 U.S. 232, 236 (1974)); see also Ashcroft v. Iqbal, 556 U.S. 662, 684 (2009)(“Our decision in Twombly expounded the pleading standard for ‘all civil actions' . . . .”); Fowler v. UPMC Shadyside, 578 F.3d 203, 210 (3d Cir. 2009)(“Iqbal . . . provides the final nail in the coffin for the ‘no set of facts' standard that applied to federal complaints before Twombly.”).

         III.

         Defendant asserts the following arguments: (1) Dr. Shah lacks standing because the applicable ERISA plan contains an anti-assignment clause; (2) the suit is barred by the Plan's limitations period; (3) the breach of contract claim (Count One) is preempted by ERISA; and (4) Count Four, violation of 29 ...


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