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Shah v. Blue Cross Blue Shield of Michigan

United States District Court, D. New Jersey

May 10, 2018



          MICHAEL E. HOLZAPFEL BECKER LLC On behalf of Defendant


          NOEL L. HILLMAN, U.S.D.J.

         This case is similar to numerous other cases filed by this plaintiff and related plaintiffs in this District[1] asserting claims by an out-of-network physician, as a purported assignee of his patient's rights, against a benefits plan for violations of the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001 et seq. Plaintiff claims the benefits plan paid him $7, 106.44 for what he valued to be a $238, 310.00 elective spinal surgery.

         Defendant has moved for summary judgment in its favor on all of Plaintiff's claims, arguing that the patient's purported assignment of her rights to Plaintiff is invalid, and even if it is valid, Defendant is entitled to judgment in its favor that it did not act arbitrarily and capriciously when it reimbursed Plaintiff according to its plan terms governing payments to out-of-network providers. For the reasons expressed below, Defendant's motion will be granted.


         On February 3, 2016, Plaintiff, Rahul Shah, M.D., who practices in New Jersey, performed a non-emergency, elective, outpatient spinal surgery on his patient, Sheila H., who resides in Pennsylvania. The patient had health coverage through a self-insured group health benefits plan sponsored and funded by Kellogg Company (the “Plan”), which the Kellogg Company made available to its active, regular, full-time employee members, and their dependents, of the Bakery, Confectionary, Tobacco Workers' and Grain Millers Local 6 Union in Pennsylvania. As of January 1, 2016, the Kellogg Company retained Defendant Blue Cross Blue Shield of Michigan (“BCBSM”) to provide claims administration services for the Plan. As an “employee welfare benefit plan, ” the Plan is governed by and subject to ERISA.

         At the time of the surgery, Plaintiff was an out-of-network, nonparticipating provider under the Plan. The patient purportedly assigned her rights to benefits under the Plan to Plaintiff, who then filed for reimbursement for the surgery from Defendant. Plaintiff submitted a claim for $238, 310.00, and the Plan paid Plaintiff $7, 106.44. Plaintiff followed the Plan's appeal process, with the Plan ultimately concluding that the reimbursement amount was properly calculated at the rate prescribed by the Plan.

         Plaintiff argues that he charged usual, customary, and reasonable (“UCR”) rates and that a common sense interpretation of the Plan dictates that it reimburse out-of-network providers at 70% of the provider's UCR charges. Plaintiff contends that the Plan violated ERISA by not reimbursing him 70% of his UCR rates, and instead improperly paid him only 70% of 150% of the Medicare reimbursement rate, a rate not listed anywhere in the Plan. Plaintiff claims that Defendant violated ERISA § 502(a)(1)(B)[2] and demands additional benefits owed to him, and also alleges a breach of fiduciary duty in violation of ERISA § 404.[3] Plaintiff seeks $231, 203.56 in unpaid benefits, plus interest, attorney's fees, and costs.

         Defendant has moved for summary judgment in its favor. Plaintiff has opposed Defendant's motion.


         A. Subject matter jurisdiction

         Defendant removed this action to this Court from the Superior Court of New Jersey, Law Division, Cumberland County pursuant to 28 U.S.C. §§ 1331, 1441(a) & (c), and 28 U.S.C. § 1446. Federal question jurisdiction exists in this matter pursuant to 28 U.S.C. § 1331, which provides that the district court has original jurisdiction of “all civil actions arising under the Constitution, laws or treaties of the United States.” ERISA further provides that the district courts of the United States shall have at least concurrent, and sometimes exclusive, jurisdiction over the ERISA causes of action pleaded in the complaint. 29 U.S.C. § 1132(e)(1).

         B. Standard for Summary Judgment

         Summary judgment is appropriate where the Court is satisfied that the materials in the record, including depositions, documents, electronically stored information, affidavits or declarations, stipulations, admissions, or interrogatory answers, demonstrate that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law. Celotex Corp. v. Catrett, 477 U.S. 317, 330 (1986); Fed.R.Civ.P. 56(a).

         An issue is “genuine” if it is supported by evidence such that a reasonable jury could return a verdict in the nonmoving party's favor. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986). A fact is “material” if, under the governing substantive law, a dispute about the fact might affect the outcome of the suit. Id. In considering a motion for summary judgment, a district court may not make credibility determinations or engage in any weighing of the evidence; instead, the non-moving party's evidence “is to be believed and all justifiable inferences are to be drawn in his favor.” Marino v. Industrial Crating Co., 358 F.3d 241, 247 (3d Cir. 2004)(quoting Anderson, 477 U.S. at 255).

         Initially, the moving party has the burden of demonstrating the absence of a genuine issue of material fact. Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986). Once the moving party has met this burden, the nonmoving party must identify, by affidavits or otherwise, specific facts showing that there is a genuine issue for trial. Id. Thus, to withstand a properly supported motion for summary judgment, the nonmoving party must identify specific facts and affirmative evidence that contradict those offered by the moving party. Anderson, 477 U.S. at 256-57. A party opposing summary judgment must do more than just rest upon mere allegations, general denials, or vague statements. Saldana v. Kmart Corp., 260 F.3d 228, 232 (3d Cir. 2001).

         C. Analysis

         1. Whether Plaintiff has standing to bring his claims

         Defendant argues that the Plan participant's assignment of benefits to Plaintiff is invalid, and Plaintiff therefore lacks standing to bring his claims.[4] Plaintiff disagrees, arguing that the assignment is unambiguous and clearly assigns to him the participant's right to benefits under the Plan, as well as the ability to bring suit against the Plan.

         “[A] federal court generally may not rule on the merits of a case without first determining that it has jurisdiction over the category of claim in suit (subject-matter jurisdiction) and the parties (personal jurisdiction).”[5] Sinochem Int'l Co. v. Malay. Int'l Shipping Corp., 549 U.S. 422, 430-31 (2007). “‘Without jurisdiction the court cannot proceed at all in any cause'; it may not assume jurisdiction for the purpose of deciding the merits of the case.” Id. at 431 (quoting Steel Co. v. Citizens for Better Env't, 523 U.S. 83, 94 (1998)). The standing requirement is no different for an action brought under ERISA. See Leuthner v. Blue Cross & Blue Shield of Ne. Pa., 454 F.3d 120, 125 (3d Cir. 2006) (providing that a plaintiff must have constitutional, prudential, and statutory standing to bring a civil action under ERISA).

         ERISA confers standing upon a participant in, or beneficiary of, an ERISA plan by allowing that participant or beneficiary to bring a civil action to “recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan.” 29 U.S.C. § 1132(a)(1)(B). This provision also confers standing upon a medical provider to sue the plan through an assignment from a plan participant. American Chiropractic Ass'n v. American Specialty Health Inc., 625 Fed.Appx. 169');">625 Fed.Appx. 169, 174-75 (3d Cir. 2015) (quoting CardioNet, Inc. v. CIGNA Health Corp., 751 F.3d 165, 176 n.10 (3d Cir. 2014)).[6]

         An assignment of the right to payment assigns the right to enforce that right by bringing suit under ERISA to collect money owed. Id. (citing N. Jersey Brain & Spine Ctr. v. Aetna, Inc., 801 F.3d 369 (3d Cir. 2015)). Such an assignment “serves the interest of patients by increasing their access to care” and reduces the likelihood of medical providers “billing the beneficiary directly and upsetting his finances.” Id. (quoting CardioNet, 751 F.3d at 179 (quotation marks omitted)). The right to enforce also recognizes that most providers, as ...

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