United States District Court, D. New Jersey
University Spine Ctr.
Anthem Blue Cross Life & Health Ins. Co.
C. Nowak, Esq. Callagy Law, P.C. Counsel for Plaintiff.
L. Genovese, Esq. Troutman Sanders LLP Counsel for Defendant.
LETTER OPINION FILED WITH THE CLERK OF THE
D. WIGENTON, U.S.D.J.
this Court is Defendant Anthem Blue Cross Life and Health
Insurance Company's “Defendant” Motion to
Dismiss Plaintiff University Spine Center's
“Plaintiff” Complaint pursuant to Federal Rule of
Civil Procedure 12b1 and 6. This Court having considered the
parties' submissions, and having reached its decision
without oral argument pursuant to Federal Rule of Civil
Procedure 78, for the reasons discussed below, GRANTS
Defendant's motion in part and DENIES Defendant's
motion in part.
& PROCEDURAL HISTORY
On or about August 31, 2015, Plaintiff, a healthcare provider
located in Passaic County, New Jersey, provided medical
services to Clinton L. “Patient”. Compl.
¶¶ 4-5. Plaintiff alleges it obtained an assignment
of benefits from Patient in to bring a claim under the
Employee Retirement Income Security Act of 1974
“ERISA”, 29 U.S.C. § 1002, et seq.
Id. ¶ 6. Plaintiff then demanded reimbursement
from Defendant in the amount of $301, 568.00, of which
Defendant paid $9, 771.48. Id. ¶¶ 7-8.
Plaintiff alleges that it “engaged in the applicable
administrative appeals process maintained by Defendant”
but Defendant denied the appeal and refused to make
additional payment. Id. ¶¶ 9-11. On August
31, 2017, Plaintiff filed a three-count Complaint in the
Superior Court of New Jersey, Law Division, Passaic County,
alleging breach of contract, failure to make payments
pursuant to Patient's Plan, and breach of fiduciary duty.
Dkt. No. 1-1. Defendant removed to this Court on October 19,
2017 and filed the instant motion to dismiss on December 4,
2017, alleging Plaintiff lacks standing to bring suit and has
failed to state claims upon which relief can be granted. Dkt.
Nos. 1, 7. Plaintiff filed its opposition on January 22, 2018
and Defendant replied on January 29, 2018. Dkt. Nos. 9,
Federal Rules of Civil Procedure provide that a complaint
must be dismissed if the district court lacks subject matter
jurisdiction. Fed.R.Civ.P. 12(b)(1). “Ordinarily, Rule
12(b)(1) governs motions to dismiss for lack of standing, as
standing is a jurisdictional matter.” N.J. Brain
& Spine Ctr. v. Aetna, Inc., 801 F.3d 369, 372 n.3
(3d Cir. 2015). However, in a case where a party claims
derivative standing to sue under ERISA § 502(a), a
motion to dismiss for lack of standing is “properly
filed under Rule 12(b)(6).” Id. Therefore, the
standard of review for both of Plaintiff's Rule 12(b)
motions is the same.
survive a motion to dismiss under Federal Rule of Civil
Procedure 12(b)(6), a complaint must include “a short
and plain statement of the claim showing that the pleader is
entitled to relief.” Fed.R.Civ.P. 8(a)(2). This Rule
“requires more than labels and conclusions, and a
formulaic recitation of the elements of a cause of action
will not do. Factual allegations must be enough to raise a
right to relief above the speculative level[.]”
Bell Atl. Corp. v. Twombly, 550 U.S. 544, 555 (2007)
(internal citations omitted); see also Phillips v. Cty.
of Allegheny, 515 F.3d 224, 231 (3d Cir. 2008) (stating
that Rule 8 “requires a ‘showing, ' rather
than a blanket assertion, of an entitlement to
relief”). In considering a Motion to Dismiss under Rule
12(b)(6), the Court must “accept all factual
allegations as true, construe the complaint in the light most
favorable to the plaintiff, and determine whether, under any
reasonable reading of the complaint, the plaintiff may be
entitled to relief.” Phillips, 515 F.3d at 231
(external citation omitted). However, “the tenet that a
court must accept as true all of the allegations contained in
a complaint is inapplicable to legal conclusions. Threadbare
recitals of the elements of a cause of action, supported by
mere conclusory statements, do not suffice.”
Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009); see
also Fowler v. UPMC Shadyside, 578 F.3d 203 (3d Cir.
2009) (discussing the Iqbal standard).
first argues that Plaintiff lacks standing to bring a claim.
ERISA Section 502(a) permits claims brought by a
“participant” or “beneficiary.” 29
U.S.C. § 1132(a) (1)-(4). A “participant” is
defined as “any employee or former employee of an
employer, or any member or former member of an employee
organization, who is or may become eligible to receive a
benefit of any type from an employee benefit plan which
covers employees of such employer or members of such
organization, or whose beneficiaries may be eligible to
receive any such benefit.” 29 U.S.C. § 1002(7). A
“beneficiary” is defined as “a person
designated by a participant, or by the terms of an employee
benefit plan, who is or may become entitled to a benefit
thereunder.” 29 U.S.C. § 1002(8). Here, it is
uncontested that Plaintiff is neither a participant nor a
beneficiary as defined by ERISA. Rather, Plaintiff asserts it
has derivative standing by virtue of an assignment of
Patient's benefits to Plaintiff. (Compl. ¶ 6.)
providers that are neither participants nor beneficiaries in
their own right may obtain derivative standing by assignment
from a plan participant or beneficiary.” N.J. Brain
& Spine, 801 F.3d at 372. Here, Defendant challenges
the validity of Plaintiff's alleged assignment as
“suspect” because it is dated four days prior to
the date of Patient's medical services and “only
vaguely alleges that Plaintiff received ‘an assignment
of benefits.'” (Dkt. No. 1-1 Ex. B; Def.'s Br.
at 7-8.) However, the assignment was dated within days of the
medical procedure at issue, it identifies “Blue
Cross” as Patient's insurance provider, and is
signed by Patient. (Dkt. No. 1-1 Ex. ...