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Shah v. Horizon Blue Cross Blue Shield of New Jersey

United States District Court, D. New Jersey, Camden Vicinage

February 9, 2018

RAHUL SHAH, MD, on assignment of Marjorie M., Plaintiff,
v.
HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY, Defendant.

          Samuel S. Saltman Michael Gottlieb Callagy Law PC Attorneys for Plaintiff.

          Michael E. Holzapfel Becker LLC Attorney for Defendant.

          OPINION

          RENÉE MARIE BUMB, UNITED STATES DISTRICT JUDGE

         This is one of many ERISA suits in this District wherein Plaintiff Dr. Rahul Shah (“Dr. Shah”), as assignee of his patients, seeks to recover additional health insurance payments he alleges are due under each patient's health insurance plan. Defendant, Horizon Blue Cross Blue Shield of New Jersey (“Horizon”), moves for summary judgment. For the reasons stated herein, the motion will be granted.

         I. FACTUAL BACKGROUND AND PROCEDURAL HISTORY

         Dr. Shah performed spinal surgery on his patient, Marjorie M., on June 5, 2013. (Statement of Undisputed Material Facts, “SUMF”, ¶ 1) Horizon was Marjorie M.'s health insurer at all relevant times. (SUMF ¶ 2) Dr. Shah was an “out-of-network” provider under the Horizon Plan. (SUMF ¶ 4) Dr. Shah submitted to Horizon $316, 643.00 in “charges” for the surgery, but Horizon only paid $8, 363.16. (Holzapfel Cert. Ex. G)

         Dr. Shah, as Marjorie M.'s assignee, administratively appealed Horizon's payment decision. (SUMF ¶ 16) Horizon denied the appeal, concluding that the claim was processed correctly under the terms of the Plan. (SUMF ¶ 17)

         The relevant portions of the Plan provide:

Schedule of Covered Services and Supplies
“Surgical Services; Out-of-Network Inpatient - Subject to Deductible and 60% Coinsurance.”
Definitions
“Deductible - The amount of Covered Charges that a Covered Person must pay before this Program provides any benefits for such charges.”
“Coinsurance - The percent applied to Covered Charges (not including Deductibles) for certain Covered Services or Supplies in order to calculate benefits under the Program. . . .”
“Covered Charges -- The authorized charges, up to the Allowance, for Covered Services and ...

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