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University Spine Center v. Horizon Blue Cross Blue Shield of New Jersey

United States District Court, D. New Jersey

June 12, 2017

UNIVERSITY SPINE CENTER o/a/o MARIA C, Plaintiff,
v.
HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY and CAREFIRST OF MARYLAND, Defendants.

          OPINION

          KEVIN MCNULTY UNITED STATES DISTRICT JUDGE.

         This is 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.

         CareFirst 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 patient.[1]

         For the 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.

         I. Background[2]

         A. Procedural History

         The 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.

         On 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. § 1132(e)(1).

         On 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 for decision.

         The 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.

         B. The Complaint

         The 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 follows.

         University 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)

         University obtained what it calls an Assignment of Benefits[3] from Maria C. The operative language on the first page of the Exhibit reads as follows:

         Assignment and Release

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)

         The operative language on the following page of the Exhibit (actually designated as page 6 in the original) reads as follows:

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 ...

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