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Shah v. Horizon Blue Cross Blue Shield of New Jersey

United States District Court, D. New Jersey

September 27, 2017

RAHUL SHAH, MD, o/a/o Edward H., Plaintiff,
v.
HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY, et al., Defendants.

          MICHAEL GOTTLIEB CALLAGY LAW, PC On behalf of Plaintiff

          MICHAEL E. HOLZAPFEL BECKER LLC On behalf of Defendants

          OPINION

          NOEL L. HILLMAN, U.S.D.J.

         This is one of many ERISA suits in this District filed by purported assignees - here, Plaintiff Rahul Shah, M.D. - of individual patients against the patients' various insurance companies - here, Defendants Horizon Blue Cross Blue Shield of New Jersey and Blue Cross Blue Shield of Minnesota.[1] The assignees claim the defendant insurance companies wrongfully denied requests for payment of benefits under the patients' health insurance policies, and, consequently, bills for services were not fully paid.

         Presently before the Court is Defendant's Motion to Dismiss the complaint pursuant to Federal Rule of Civil Procedure 12(b)(6). For the reasons expressed below, Defendant's motion will be granted in part, denied in part, and denied as moot in part.

         I.

         We take our facts from Plaintiff's November 23, 2016 complaint. On April 27, 2015, Plaintiff performed a cervical fusion procedure on Edward H. (“Patient”). Defendant administered Patient's employee welfare benefit plan (“Plan”). Plaintiff obtained an assignment of benefits from Patient, pursuant to which Plaintiff completed a Health Insurance Claim Form demanding a $255, 695 reimbursement for Patient's surgical procedure. Defendant paid $16, 014.88. Accordingly, Plaintiff alleges he is still due $239, 680.12.

         Plaintiff brings claims for breach of contract; failure to make payments under 29 U.S.C. § 1132(a)(1)(B); breach of fiduciary duty under 29 U.S.C. § 1132(a)(3), 29 U.S.C. § 1104(a)(1), and 29 U.S.C. § 1105(a); and failure to maintain reasonable claims procedures under 29 C.F.R. 2560.503-1. Defendant subsequently filed a motion to dismiss for failure to state a claim.

         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 the defendant fair notice of what the plaintiff's claim is and the grounds upon which it rests.'” Baldwin Cty. Welcome Ctr. v. Brown, 466 U.S. 147, 149-50 n.3 (1984) (quoting Conley v. Gibson, 355 U.S. 41, 47 (1957)).

         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 Atl. 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) Plaintiff lacks standing due to the anti-assignment clauses in the Plan; (2) Plaintiff failed to sufficiently allege exhaustion of administrative remedies; (3) Plaintiff's state law claims are preempted by ERISA; and (4) Plaintiff's claim of violation of 29 C.F.R. ...


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