United States District Court, D. New Jersey
MICHAEL GOTTLIEB SAMUEL S. SALTMAN CALLAGY LAW PC MACK-CALI
CENTRE II On behalf of Plaintiff
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
L. HILLMAN, U.S.D.J.
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
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.
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
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.
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.
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
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. On February 21, 2017, this Court
dismissed Count One and Count Four of the First Amended
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 ...