United States District Court, D. New Jersey
MCNULTY UNITED STATES DISTRICT JUDGE.
an action under the Employment Retirement Income Security Act
of 1974 ("ERISA"), 29 U.S.C. § 1001 et
seq. University Spine Center ("University"),
an out-of-network provider, billed its patient for some $374,
000 in services; defendant CareFirst of Maryland
("CareFirst"), as claims administrator, paid out
approximately $9, 100. Seeking to recover the adjusted
balance from CareFirst, University sues as assignee of its
patient, Maria C.
moves under Fed.R.Civ.P. 12(b)(6) to dismiss the Complaint
for failure to state a claim upon which relief may be
granted. Primarily, CareFirst contends that the relevant
health benefits plan contains a no-assignment clause that
bars University from suing as the assignee of its
reasons stated herein, I agree with CareFirst, and with cases
decided in this District addressing the same issue, and I
will grant the motion to dismiss.
Complaint was originally filed in New Jersey Superior Court,
Passaic County, on September 26, 2016. It essentially seeks
reimbursement for a claim denied under a health insurance
plan. It contains one count of state-law breach of contract,
and three ERISA-related counts.
November 3, 2016, the defendants filed a notice of removal to
federal court. (ECF no. 1 at 1) The plan, they stated, is
covered by ERISA. See 29 U.S.C. § 1002(1).
Hence all related claims are preempted by federal law,
see 29 U.S.C. § 1144(a), and this Court has
jurisdiction, see 28 U.S.C. § 1331 and 29 U.S.C. §
January 13, 2017, the defendants, CareFirst and Horizon Blue
Cross Blue Shield of New Jersey ("Horizon"), filed
a motion (ECF no. 9) to dismiss the Complaint for failure to
state a claim upon which relief may be granted. See
Fed.R.Civ.P. 12(b)(6). University filed a response. (ECF no.
11) The defendants filed a reply. (ECF no. 12) Although
defendants sought time to decide whether to amend their
Complaint in response to the motion, they have now stated
definitively that they do not seek to amend the Complaint.
(ECF nos. 19, 20) The motion is now fully briefed and ripe
parties agree that the case is governed by ERISA.
Accordingly, University has agreed to voluntarily dismiss
Count 1 of the Complaint, a state law breach of contract
claim. (See PI. Brf. 1.) In addition, the parties
have by stipulation dismissed defendant Horizon from the
case. (ECF nos. 16, 17) What remains, then, is a motion by
Carefirst, the remaining defendant, to dismiss Counts 2, 3,
and 4, the remaining counts of the Complaint.
allegations of the complaint (ECF no. 1 at 11, cited as
"Cplt."), taken as true for purposes of this
motion, see Section II, infra, are as
provided medical services to Maria C. between September 10,
2015, and February 1, 2016. The services consisted of spinal
surgery and related matters. (Cplt. ¶ 4 8b Ex. A)
obtained what it calls an Assignment of
Benefits from Maria C. The operative language on
the first page of the Exhibit reads as follows:
I, the undersigned, certify that I (or my dependent/s) have
insurance coverage with BC/BS and assign directly to
University Spine Center, all insurance benefits, if any,
otherwise payable to me for the services rendered. I
understand that I am financially responsible for all charges,
whether or not paid by insurance. I hereby authorize the
doctor to release all information necessary to secure the
payment of benefits. I authorize the use of this signature on
all insurance submissions.
Responsible Party Signature: [redacted]
Relationship: self Dated: 9/10/15
(Assignment of Benefits, ECF no. 1 at 45)
operative language on the following page of the Exhibit
(actually designated as page 6 in the original) reads as
I, [redacted], understand that I am utilizing my out of
network benefits and that my insurance company may send to
me, the payment(s) for services by University Spine Center in
my treatment. I also understand that by paying a partial
payment at the time services are rendered, in no way means
the doctors are in network. I understand that the partial
payment collected will be posted to my account as a payment
towards my co/insurance and or deductible. I agree to sign
over the full amount to University Spine Center within thirty
days of receipt of the same. If I fail to do so, I understand
that in addition to being responsible for the full amount
charged by University Spine Center for said services, I will
be responsible for any charge incurred by him in pursuing and
collecting from me.
I authorize payment of medical benefits for service performed
by University Spine Center ...