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Shah v. Horizon Blue Cross Blue Shield

United States District Court, D. New Jersey

March 27, 2018

RAHUL SHAH, on assignment of JOANNE G., Plaintiff,
v.
HORIZON BLUE CROSS BLUE SHIELD and BLUE ADVANTAGE ADMINISTRATORS OF ARKANSAS, Defendants.[1]

          MICHAEL GOTTLIEB SAMUEL S. SALTMAN CALLAGY LAW PC MACK-CALI CENTRE II On behalf of Plaintiff

          J. GORDON HOWARD, PRO HAC VICE RUSSELL & OLIVER, PLC On behalf of Defendant Blue Advantage Administrators of Arkansas

          JEFFREY MATTHEW BRENNER MARNI SABRINA BERGER STEVEN SCHILDT POST & SCHELL PC FOUR PENN CENTER PLAZA On behalf of Defendant Blue Advantage Administrators of Arkansas

          OPINION

          NOEL L. HILLMAN, U.S.D.J.

         This is one of many ERISA suits filed by Plaintiff Dr. Rahul Shah, as purported assignee of his individual patients, against his patients' various insurance companies. In each suit, Plaintiff asserts that the insurance companies wrongfully denied requests for payment of benefits under the patients' health insurance policies, and consequently, Plaintiff's bills for service were not paid, or not fully paid.

         Presently before the Court is Defendant's Motion for Summary Judgment. For the reasons that follow, the Court will grant the motion and enter summary judgment in favor of Defendant.

         I.

         The Court takes its facts from Defendant's Statement of Undisputed Material Facts, Plaintiff's Response and Statement of Material Facts, and Defendant's Response to Plaintiff's Statement.

         Plaintiff is a spinal surgeon who, on July 31, 2013, performed spinal surgery on Joanne G. Her treatment included a full bilateral laminectomy and fusion, among other surgical procedures of the lumbar spine. The total charge for the surgical treatment was $174, 922. Of the $174, 922 charge for the surgical treatment, $3, 930.93 was the amount allowed under the terms of the plan. The total non-covered amount was $170, 991.07. Plaintiff proffers that, because the $3, 930.93 was applied to Joanne G.'s deductible, Plaintiff was ultimately responsible for the entire $174, 922.

         Joanne G. was a participant in the Wal-Mart Stores, Inc. Associates' Health and Welfare Plan (“the Plan”), a self-funded employee welfare benefit plan governed by ERISA. USAble Mutual Insurance Company, doing business as BlueAdvantage Administrators of Arkansas (“BlueAdvantange”) is the third-party administrator who processed Joanne G.'s benefit claims. Plaintiff is an out-of-network provider.

         Joanne G. signed a May 14, 2013 assignment which does not reference Plaintiff, referring solely to “Premier Orthopaedic Associates of Southern NJ, LLC.” It states, in part, that Joanne G. “irrevocably assign[s] to you, my medical provider, all of my rights and benefits under my insurance contract for payment for services rendered to me.” A second assignment was executed on December 19, 2015, which lists Premier Orthopaedic Associates of Southern New Jersey, Thomas A. Dwyer, Plaintiff, and Christian Brenner.

         Plaintiff brings this action as an alleged assignee of Joanne G. Plaintiff filed its initial complaint on March 23, 2016 in New Jersey Superior Court, followed by a June 6, 2016 Amended Complaint. The Amended Complaint asserted four counts: (1) breach of contract, (2) failure to make payments under 29 U.S.C. § 1132(a)(1)(B), (3) breach of fiduciary duty under 29 U.S.C. § 1132(a)(3), 1104(a)(1), 1105(a), and (4) failure to establish/maintain reasonable claims procedures under 29 C.F.R. 2560.503-1. The case was removed to federal court on May 4, 2016.[2] On February 21, 2017, this Court dismissed Count One and Count Four of the First Amended Complaint.

         II.

         Summary judgment is appropriate where the Court is satisfied that “'the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits if any, ' . . . demonstrate the absence of a genuine issue of material fact” and that the moving party is entitled to a judgment as a ...


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