United States District Court, D. New Jersey
MICHAEL GOTTLIEB CALLAGY LAW, PC On behalf of Plaintiff
MICHAEL E. HOLZAPFEL BECKER LLC On behalf of Defendants
L. HILLMAN, U.S.D.J.
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. 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.
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.
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.
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.
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.”
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)).
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
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