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Shah v. Blue Cross Blue Shield of New Jersey

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

March 13, 2018

RAHUL SHAH, M.D., o/a/o DENNIS C., Plaintiff,

          Michael Gottlieb, Esq. Callagy Law, Attorneys for Plaintiff.

          Anne B. Sekel, Esq. Foley & Lardner, LLP Attorneys for Defendant.



         This 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.

         I. Factual and Procedural Background [1]

         On 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).

         After 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).

         Unsatisfied 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).

         On 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.

         On 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. ¶ 51-68).

         Pursuant 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].

         II. Motion to Dismiss Standard

         To 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)).

         Rule 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. 1993).

         III. ...

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