United States District Court, D. New Jersey
WILLIAM J. MARTINI, U.S.D.J.
University Spine Center, on assignment of Edward C.
(“Patient”), brings this action against Defendant
Anthem Blue Cross Blue Shield, alleging failure to make all
payments under Patient's medical plan pursuant to the
Employee Retirement Income Security Act of 1974
(“ERISA”), 29 U.S.C. § 1132(a), and breach
of fiduciary duty. This matter comes before the Court on
Defendant's motion to dismiss pursuant to Federal Rules
of Civil Procedure 12(b)(1) and (b)(6). There was no oral
argument. Fed.R.Civ.P. 78(b). For the reasons set forth
below, Defendant's motion to dismiss is
is a healthcare provider in the Passaic County, New Jersey.
Compl. ¶ 1, ECF No. 1. Defendant administers health
insurance plans to individuals in New Jersey, among other
states. See id. ¶ 2; Def.'s Mem. of Law in
Supp. of Its Mot. to Dismiss (“Def.'s Mem.”)
4-5, ECF No. 6-1. At all relevant times, Patient was a plan
participant in the Ascena Retail Group Inc., Benefits Plan
(the “Plan”), which Defendant administered.
See Def.'s Mem. 5, Ex. A. In addition, at all
relevant times, Plaintiff was an out-of-network healthcare
provider and did not have a contract with Defendant. See
id. at 4.
November 17, 2015, Plaintiff provided Patient with medical
services, including surgery to remove and fuse cervical
disks. See Compl. ¶¶ 5-6. Patient
transferred his rights to benefit payments under the Plan to
Plaintiff. Id. ¶ 7. Plaintiff subsequently
filed a claim with Defendant for $170, 082.00 in
reimbursement for services rendered. Id. ¶ 9.
Defendant paid $15, 621.95 of that claim. See
Pl.'s Br. in Opp'n to Def.'s Mot.
(“Pl.'s Opp'n”) 12 n.2, ECF No. 8. On
January 26, 2018, Plaintiff filed suit, alleging that
Defendant failed to make all payments as required by ERISA
and breach of fiduciary duty. See Compl.
now moves to dismiss, arguing first that Plaintiff lacks
standing to assert its ERISA claim because the Plan contains
a valid and enforceable anti-assignment clause. See
Def.'s Mem. at 8-12. Defendant next argues that
Plaintiff's complaint insufficiently describes the
alleged assignment. See id. at 12-17. Defendant
further argues that Plaintiff failed to state a claim under
ERISA for additional benefits, that Plaintiff's breach of
fiduciary duty claim is duplicative, and that Plaintiff
failed to exhaust its administrative remedies. See
id. at 17-25.
opposes, arguing that the anti-assignment clause does not
preclude its standing to sue. See Pl.'s
Opp'n at 17-28. Plaintiff further argues that
Defendant's reliance on Rule 12(b)(1) is erroneous, that
Plaintiff adequately alleged the existence of the assignment,
that its breach of fiduciary duty claim is non-duplicative
pursuant to Supreme Court precedent, and that Defendant's
failure to comply with reasonable claims procedures prevents
dismissal based on Plaintiff's failure to exhaust its
administrative remedies. See id. at 12-15, 28-34.
Defendant filed a reply, largely reiterating its previous
arguments, including Plaintiff's lack of standing.
See Def.'s Reply Mem. of Law in Further Supp. of
Its Mot. to Dismiss, ECF No. 9.
Rule of Civil Procedure 12(b)(1) provides for the dismissal
of a complaint for lack of subject matter jurisdiction.
Fed.R.Civ.P. 12(b)(1). There are two types of challenges to
subject-matter jurisdiction: (1) facial attacks, which
challenge the allegations of the complaint on their face; and
(2) factual attacks, which challenge the existence of
subject-matter jurisdiction, quite apart from any pleadings.
Mortensen v. First Fed. Sav. & Loan Ass'n,
549 F.2d 884, 891 (3d Cir. 1977). In reviewing a factual
attack, as Defendant presents here, the court may consider
evidence outside the pleadings, and no presumptive
truthfulness attaches to the plaintiff's allegations.
Gould Elecs. Inc. v. United States, 220 F.3d 169,
176 (3d Cir. 2000); Gotha v. United States, 115 F.3d
176, 178-79 (3d Cir. 1997). The plaintiff bears the burden of
proving that jurisdiction exists. Gould Elecs., 220
F.3d at 178.
Rule of Civil Procedure 12(b)(6) provides for the dismissal
of a complaint, in whole or in part, if the plaintiff fails
to state a claim upon which relief can be granted. The moving
party bears the burden of showing that no claim has been
stated. Hedges v. United States, 404 F.3d 744, 750
(3d Cir. 2005). In deciding a motion to dismiss under Rule
12(b)(6), a court must take all allegations in the complaint
as true and view them in the light most favorable to the
plaintiff. See Warth v. Seldin, 422 U.S. 490, 501
(1975); Trump Hotels & Casino Resorts, Inc. v. Mirage
Resorts Inc., 140 F.3d 478, 483 (3d Cir. 1998).
a complaint need not contain detailed factual allegations,
“a plaintiff's obligation to provide the
‘grounds' of his ‘entitlement to relief'
requires more than labels and conclusions, and a formulaic
recitation of the elements of a cause of action will not
do.” Bell Atl. Corp. v. Twombly, 550 U.S. 544,
555 (2007). Thus, the factual allegations must be sufficient
to raise a plaintiff's right to relief above a
speculative level, such that it is “plausible on its
face.” See Id. at 570; see also Umland v.
PLANCO Fin. Serv., Inc., 542 F.3d 59, 64 (3d Cir. 2008).
“A claim has facial plausibility when the plaintiff
pleads factual content that allows the court to draw the
reasonable inference that the defendant is liable for the
misconduct alleged.” Ashcroft v. Iqbal, 556
U.S. 662, 678 (2009) (citing Twombly, 550 U.S. at
556). While “[t]he plausibility standard is not akin to
a ‘probability requirement' . . . it asks for more
than a sheer possibility.” Id.
requirement that jurisdiction be established as a threshold
matter ‘spring[s] from the nature and limits of the
judicial power of the United States' and is
‘inflexible and without exception.'”
Steel Co. v. Citizens for a Better Env't, 523
U.S. 83, 94-95 (1998) (quoting Mansfield, C. & L.M.R.
Co. v. Swan, 111 U.S. 379, 382 (1884)). Defendant
challenges Plaintiff's standing to sue based on the
anti-assignment clause located in the Plan documents,
restraining Patient from assigning his benefits. See
Def.'s Mem. at 9-12. Plaintiff argues that the
anti-assignment clause is invalid for multiple reasons.
See Pl.'s Opp'n at 17-28. The
anti-assignment clause in question reads as follows:
You cannot assign your right to receive
to anyone else, except as required by a
“Qualified Medical Child Support order” as
defined by ...