United States District Court, D. New Jersey
litigation is one of many in which out-of-network health care
providers, purporting to sue on behalf of their patients,
have sought to be reimbursed at (or at least closer to)
in-network rates. Plaintiff University Spine Center
("University Spine"), an out-of-network provider,
brings this Employment Retirement Income Security Act of 1974
("ERISA"), 29 U.S.C. §§ 1001 et
seq., action against defendant Aetna, Inc.
("Aetna"), the claims administrator for the health
plan of University Spine's patient. University Spine sues
as assignee of a patient, L.K., and seeks to recover $133,
now moves under Fed.R.Civ.P. 12(b)(6) to dismiss the
Complaint for failure to state a claim upon which relief may
reasons stated herein, I will deny the motion to dismiss.
Complaint was originally filed by University Spine in New
Jersey Superior Court, Passaic County, on August 30, 2017.
(Compl.) The Complaint contains three claims against Aetna:
(1) breach of contract; (2) failure to make all payments
pursuant to the member's plan under ERISA; and (3) breach
of fiduciary duty under ERISA. (Id. at ¶¶
October 12, 2017, Aetna filed a Notice of Removal to federal
court pursuant to 28 U.S.C. §§ 1441 and 1446. The
Notice states three grounds for removal: "(1) Count II
and Count III explicitly allege claims that arise under
federal law; (2) the parties are completely diverse and the
amount in controversy exceeds the jurisdictional threshold;
and (3) Count I is completely preempted by ERISA Section
502(a)." (Id. at ¶ 5). (See also
Id. at ¶¶ 6-8.) Aetna attached three Exhibits
to the Notice, including the Complaint and its corresponding
Exhibits, (ECF no. 1-1).
week later, on October 19, 2017, Aetna filed a motion under
Federal Rule of Civil Procedure 12(b)(6) to dismiss the
Complaint with prejudice for failure to state a claim. (Def.
November 6, 2017, University Spine filed an opposition to
Aetna's motion to dismiss. (PI. Brf.) One week later, on
November 13, 2017, Aetna filed a reply. (ECF no. 7).
December 21, 2017, Aetna filed a notice of supplemental
authority in support of its pending motion to dismiss. (ECF
no. 10 (attaching ECF no. 10-1, a copy of Univ. Spine
Ctr. v. Aetna, Inc., No. CV 17-7825 (JLL), 2017 WL
6514663 (D.N.J. Dec. 20, 2017)).
parties agree that the case is governed by ERISA. Therefore,
University Spine has agreed to voluntarily dismiss Count I, a
state law breach of contract claim. See (PI. Brf.
3). Accordingly, I will consider Aetna's motion to
dismiss as to the ERISA-related claims, Counts 2 and 3.
December 30, 2016, University Spine provided medical services
to L.K. (Compl. ¶¶ 3-4). The services consisted of
a spinal surgery and related procedures. (Id. at
Spine received an Assignment of Benefits from L.K. (Compl.,
Exh. B). The Assignment of Benefits form states, in relevant
I, the undersigned, certify that I (or my dependent/s) have
insurance coverage with __and assign directly to University
Spine Center, all insurance benefits, if any, otherwise
payable to me for the services rendered. I understand that I
am financially responsible for all charges, whether or not
paid by insurance. I hereby authorize the doctor to release
all information necessary to secure the payment of benefits.
I authorize the use of this signature on all insurance
Responsible Party Signature:
[redacted] Relationship: self
time medical services were provided, L.K. was a member of
Aetna Choice POS II, a self-funded health benefits plan.
See (ECF no. 3-3, ¶ 3; ECF no. 3-4, Exh. 1;
Def. Brf. 3). Aetna is the Claims Administrator for the Plan.
(Compl. ¶ 14). The terms of the Plan are set forth in a
booklet entitled "What Your Plan Covers and How Benefits
are Paid." (ECF no. 3-4, Exh. A). As stated above, the
parties do not dispute that the Plan is governed by ERISA.
Spine is an out-of-network health care provider as to the
Plan. It sues pursuant to the Assignment of Benefits. (Compl.
¶¶ 26, 32). However, die Plan includes an
anti-assignment clause. (ECF no. 3-4, Exh. A at 59). In a
section entitled "Assignments, " it provides as
follows: "Coverage and your rights under this Aetna
medical benefits plan may not be assigned. A direction to pay
a provider is not an assignment of any right under this plan
or of any legal or equitable right to institute any court
proceeding." Id. (emphasis in original).
assignee, University Spine submitted a Health Insurance Claim
Form to Aetna for the services it provided to L.K. (Compl.
¶ 7)(citing Exh. C). It requested reimbursement in the
amount of $137, 713.00. (Id.) However, only $4,
392.02 has been reimbursed by Aetna. (Id. at ¶
letter dated February 28, 2017, University Spine requested
that Aetna immediately reprocess the claim. (Compl., Exh. E).
It also requested that if Aetna decided not to pay additional
benefits, it provide a written explanation as to its
three weeks later, in a letter dated March 20, 2017,
University Spine sent Aetna a notice of appeal. (Compl.
¶ 9) (citing Exh. E). In the letter, University Spine
once again requested that the claim be reprocessed for
additional payment, and asked Aetna to provide "a
written explanation citing applicable policy language, "
pursuant to 29 C.F.R. § 2560.503-1, within 30 days if it
denied the additional payment. (Compl., Exh. E). In the
Complaint, University Spine alleges that it "requested,
among other items, a copy of the Summary Plan Description,
Plan Policy, and identification of the Plan
Administrator/Plan Sponsor." (Compl. ¶ 10)(citing
letter dated May 10, 2017, Aetna informed University Spine
that it was upholding its original benefits determination.
(Notice of Removal, Exh. F). It explained that the
reimbursement of University Spine's claim was based upon
a reasonable and customary charge. (Id.)
to University Spine, Aetna failed to provide it with a copy
of the documents it had previously requested. (Compl. ¶
about August 30, 2017, University Spine filed this action in
the Superior Court of New Jersey, Law ...