United States District Court, D. New Jersey, Camden Vicinage
Michael Gottlieb, Esq. Callagy Law, Attorneys for Plaintiff.
B. Sekel, Esq. Foley & Lardner, LLP Attorneys for
BUMB, UNITED STATES DISTRICT JUDGE [DKT. NO.
RENÉE MARIE BUMB UNITED STATES DISTRICT JUDGE.
matter comes before the Court upon the filing of a motion by
Defendant Health Care Service Corporation, a Mutual Legal
Reserve Company, doing business in Texas as Blue Cross and
Blue Shield of Texas (incorrectly identified as Blue Cross
Blue Shield of Texas) (“HCSC” or
“Defendant”) [Dkt. No. 38] seeking the dismissal
of all counts of Plaintiff Rahul Shah, M.D.'s
(“Plaintiff” or “Dr. Shah”) Amended
Complaint pursuant to Fed.R.Civ.P. 12(b)(6). For the reasons
stated herein, the motion will be granted, in part, and
denied, in part.
Factual and Procedural Background 
February 16, 2015, Dr. Shah performed spinal surgery (the
“Procedures”) on his patient, Dennis C. (the
“Patient”). (Am. Compl. ¶ 4-5). Dr. Shah
obtained an assignment of benefits from the Patient so that
he could bring claims under the Employee Retirement Income
Security Act of 1974, 29 U.S.C. § 1002, et seq.
(“ERISA”) on the Patient's behalf. (Am.
Compl. ¶6; Am. Compl. Ex. B).
performing the Procedures, and pursuant to the assignment of
benefits, Dr. Shah prepared a Health Insurance Claim Form
(“HICF”) demanding reimbursement in the amount of
$162, 466.00 from Defendant, the claims administrator of the
Patient's health insurance plan. (Am. Compl. ¶ 7,
15; Am. Compl. Ex. C). Defendant, however, paid only a
fraction of the requested amount. (Id. at ¶ 8;
Am. Compl. Ex. D).
with the amount of reimbursement he received, Dr. Shah
instituted an administrative appeal, pursuing a full
reimbursement. (Id. at ¶ 9; Am. Compl. Ex. E).
On April 1, 2015, Plaintiff submitted a letter to
“Horizon Bluecard” formally requesting an
“internal appeal/second look.” (Am. Compl. Ex.
E). In his letter, Dr. Shah also requested that he be
furnished with certain documents, including “a copy of
the Summary Plan Description, Plan Policy, and identification
of the Plan Administrator/Plan Sponsor.” (Am. Compl.
¶ 10; Am. Compl. Ex. E). On March 30, 2016, Plaintiff
submitted a letter to Defendant containing his “second
notice of appeal” and reiterating his request for
documents. (Am. Compl. Ex. E). Although Defendant responded
to the appeal, it did not furnish all of the documents
requested by Plaintiff. (Am. Compl. ¶ 11). Specifically,
Plaintiff did not receive a copy of the Summary Plan
Description until this litigation had been initiated and
proceeded to discovery. (Id. at ¶ 12).
October 4, 2016, Plaintiff filed a four count complaint in
the New Jersey Superior Court, Civil Division, Cumberland
County (No. CUM-L-699-16) against Horizon Blue Cross Blue
Shield of New Jersey (“Horizon”) and Defendant
alleging: (1) breach of contract; (2) failure to make all
payments pursuant to member's plan under 29 U.S.C. §
1132(a)(1)(B); (3) breach of fiduciary duty and co-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 (4) failure to
establish/maintain reasonable claims procedures under 29
C.F.R. 2560.503-1. [Dkt. No. 1-1]. Defendant removed the
action to federal court on November 28, 2016 on the basis of
federal question jurisdiction.
March 10, 2017, Plaintiff dismissed his claims against
Horizon without prejudice. [Dkt. No. 23]. On May 4, 2017, he
filed the Amended Complaint restating the four counts of the
initial complaint and adding two additional counts against
Defendant: (1) failure to establish a summary plan
description in accordance with 29 U.S.C. § 1022 and 29
C.F.R. § 2520.102-2 and (2) failure to provide a copy of
the summary plan description upon written request in
violation of 29 U.S.C. § 1024. (Am. Compl. ¶
to this Court's Individual Rules and Procedures, the
Defendant filed a letter on June 16, 2017 expressing its
intention to file a motion to dismiss Plaintiff's
Complaint and setting forth its arguments in support of that
proposed motion. [Dkt. No. 33]. In response, Plaintiff
indicated that he would voluntarily dismiss Counts One
(breach of contract) and Six (29 U.S.C. § 1024). [Dkt.
No. 36]. Defendant filed the pending motion to dismiss on
July 12, 2017, seeking the dismissal of all of the remaining
claims. [Dkt. No. 38].
Motion to Dismiss Standard
withstand a motion to dismiss under Federal Rule of Civil
Procedure 12(b)(6), “a complaint must contain
sufficient factual matter, accepted as true, to ‘state
a claim to relief that is plausible on its face.'”
Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009) (quoting
Bell Atlantic Corp. v. Twombly, 550 U.S. 544, 570
(2007)). “A claim has facial plausibility when the
plaintiff pleads factual content that allows the court to
draw the reasonable inference that the defendant is liable
for the misconduct alleged.” Id. at 663.
“[A]n unadorned, the defendant-unlawfully-harmed me
accusation” does not suffice to survive a motion to
dismiss. Id. at 678. “[A] plaintiff's
obligation to provide the ‘grounds' of his
‘entitle[ment] to relief' requires more than labels
and conclusions, and a formulaic recitation of the elements
of a cause of action will not do.” Twombly,
550 U.S. at 555 (quoting Papasan v. Allain, 478 U.S.
265, 286 (1986)).
12(b)(6) requires the district court to “accept as true
all well-pled factual allegations as well as all reasonable
inferences that can be drawn from them, and construe those
allegations in the light most favorable to the
plaintiff.” Bistrian, 696 F.3d at 358 n. 1.
Only the allegations in the complaint and “matters of
public record, orders, exhibits attached to the complaint and
items appearing in the record of the case” are taken
into consideration. Oshiver v. Levin, Fishbein, Sedran
& Berman, 38 F.3d 1380, 1384 n. 2 (3d Cir. 1994)
(citing Chester Cty. Intermediate Unit. v.
Pennsylvania Blue Shield, 896 F.2d 808, 812 (3d
Cir. 1990)). A court may also “consider an undisputedly
authentic document that a defendant attaches as an exhibit to
a motion to dismiss if the plaintiff's claims are based
on the document.” Pension Ben. Guar. Corp. v. White
Consol. Indus., Inc., 998 F.2d 1192, 1196 (3d Cir.