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Center for Orthopedics and Sports Medicine v. Anthem Blue Cross Life and Health Insurance Co.

United States District Court, D. New Jersey

March 22, 2018



          PETER G. SHERIDAN, U.S.D.J.

         This matter comes before the Court on Defendants Anthem Blue Cross Life and Health Insurance (hereinafter, "Anthem") and Google, Inc.'s Motions to Dismiss The Center For Orthopedics and Sports Medicine and Dr. Daniel E. Fox (hereinafter, "Plaintiff Providers"), and Patient Adrian P.'s Complaint pursuant Federal Rules of Civil Procedure 8(a), 12(b)(1) and 12(b)(6) (ECF Nos. 9 and 10). Plaintiffs initiated this suit, seeking relief under the Employment Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq. (ECF No. 1). For the reasons discussed herein, Defendants' motions to dismiss are granted in part, and denied in part.


         This case arises from a dispute over nonpayment of medical services. The Center is an out-of-network healthcare association, and Dr. Fox an out-of-network healthcare provider and licensed orthopedic surgeon. (Complaint at ¶¶ 1-2). On October 13, 2015, Dr. Fox provided medical services to Adrian P., which included ACL reconstruction surgery to Adrian P.'s right knee and related procedures. (Id. at ¶ 33). However, since the Center and Dr. Fox were out-of-network providers, they required Adrian P. "sign documents whereby the patient agree[d] to be personally responsible for all medical charges." (Id. at ¶ 16). Among these forms, Plaintiff Providers claim to have obtained an Assignment of Benefits and Limited Power of Attorney, making them beneficiaries of Adrian P.'s ERISA healthcare plan. (ECF No. 1 at 16, "Assignment of Benefits"). The Assignment of Benefits states:

I irrevocably assign to you, my medical provider, all of my rights and benefits under my insurance contract and/or any employee welfare benefit plan for payment for services rendered to me, including but not limited to all of my rights under "ERISA" applicable to the medical services at issue. I also authorize you to file insurance claims on my behalf for services rendered to me and this specifically includes filing arbitration/litigation in your name on my behalf against the PIP carrier/health care carrier. I irrevocably authorize you to retain an attorney of your choice on my behalf for collection of your bills. I direct that all reimbursable medical payments go directly to you, my medical provider. I authorize and consent to your acting on my behalf in this regard and in regard to my general health insurance coverage and I specifically authorize you to pursue any administrative appeals conducted pursuant to "ERISA."
In the event the insurance carrier responsible for making medical payments in this matter does not accept my assignment, or my assignment is challenged or deemed invalid, I execute this limited/special power of attorney and appoint and authorize your collection attorney as my agent and attorney to collect payment for your medical services directly against the carrier in this case, in my name, including filing an arbitration demand or lawsuit. I specifically authorize that attorney to file directly against that carrier in my name or in your name as a medical provider rendering services to me and designate your collection attorney as my attorney in fact. I further grant limit power of attorney to you as my medical provider to receive and collect directly from the insurance carrier money due you for services rendered to me in this matter, and hereby instruct the insurance carrier to pay you directly any monies due you for medical services you rendered to me. I authorize you and or your attorney to receive from my insurer, immediately upon verbal request all information regarding last payment made by said insurer on my claim, including date of payment and balance of benefits remaining.


         At all times relevant, Adrian P. received his health coverage through a self-funded health benefit plan provided by his wife's employer, Google, Inc., which was administered by Anthem. (Id. at ¶¶ 4-5, 10; ECF No. 9-2, "The Plan"). As an employee welfare benefit plan, the Plan is governed by ERISA. (Id. at ¶¶ 20-25). The Plan has two key provisions that are relevant for purposes of this motion:

Benefits Not Transferable. Only the member is entitled to receive benefits under this plan. The right to benefits cannot be transferred.
Payment to Providers. The benefits of this plan will be paid directly to participating providers and medical transportation providers. Also, other providers of service will be paid directly when you assign benefits in writing. If another party pays for your medical care and you assign benefits in writing, the benefits of this plan will be paid to that party. These payments will fulfill our obligation to you for those covered services.

         (The Plan at 74). In any event, on October 15, 2015, the Center billed Anthem $74, 088.60 for its services. (Complaint at ¶ 39). Of this, Anthem only paid $6, 951.81, leaving a balance of $67, 136.79 outstanding. (Id. at ¶¶ 41, 50).

         Pursuant the assignment of benefits, Plaintiffs bring this present lawsuit seeking, among other things, reimbursement for the medical services provided to Adrian P. Specifically, Plaintiffs allege that Defendants failed to make all payments pursuant a member's plan, contrary to Section 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B). Relying principally on the "Benefits Not Transferable" clause, Defendants contend that Plaintiffs lack standing to sue. Alternatively, Defendants argue that Plaintiffs fail to plead particularized facts upon which relief may be granted.


         I. Rule 12(b)(1) Subject ...

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