United States District Court, D. New Jersey
CAPE REGIONAL MEDICAL CENTER on assignments of 52 individual patients Plaintiffs,
CIGNA HEALTH AND LIFE INS. CO., Defendant.
H. RODRIGUEZ U.S.D. JUDGE
matter has come before the Court on Defendant's Motion to
Dismiss the Complaint pursuant to Federal Rule of Civil
Procedure 12(b)(6) for failure to state a claim. The Court
has considered the submissions of the parties and decides
this motion on the papers pursuant to Federal Rule of Civil
Procedure 78(b). For the reasons stated here, Defendant's
motion [Doc. 12] will be granted.
Cape Regional Medical Center, as assignee, seeks
reimbursement of approximately $357, 416.47 of allegedly
underpaid benefits from Defendant Cigna Health and Life
Insurance Company for emergency medical services provided to
52 individual patients who were beneficiaries of
Defendant's health benefits plan governed by
to Dismiss Standard
Rule of Civil Procedure 12(b)(6) permits a motion to dismiss
“for failure to state a claim upon which relief can be
granted[.]” For a complaint to survive dismissal under
Rule 12(b)(6), it must contain sufficient factual matter to
state a claim that is plausible on its face. Ashcroft v.
Iqbal, 556 U.S. 662, 678 (2009) (quoting Bell Atl.
Corp. v. Twombly, 550 U.S. 544, 570 (2007)). A claim is
facially plausible “when the plaintiff pleads factual
content that allows the court to draw the reasonable
inference that the defendant is liable for the misconduct
alleged.” Id. Further, a plaintiff must
“allege sufficient facts to raise a reasonable
expectation that discovery will uncover proof of her
claims.” Connelly v. Lane Const. Corp., 809
F.3d 780, 789 (3d Cir. 2016). In evaluating the sufficiency
of a complaint, district courts must separate the factual and
legal elements. Fowler v. UFMC Shadyside, 578 F.3d
203, 210-11 (3d Cir. 2009) (“Iqbal ...
provides the final nail-in-the-coffin for the ‘no set
of facts' standard that applied to federal complaints
before Twombly.”). The Court “must
accept all of the complaint's well-pleaded facts as true,
” Fowler, 578 F.3d at 210, “and then
determine whether they plausibly give rise to an entitlement
for relief.” Connelly, 809 F.3d at 787
(citations omitted). Restatements of the elements of a claim,
however, are legal conclusions and, therefore, not entitled
to a presumption of truth. Burtch v. Milberg Factors,
Inc., 662 F.3d 212, 224 (3d Cir. 2011).
One, alleging a violation under N.J. Admin. Code §
11:4-37, is preempted by ERISA because it is a claim for
benefits allegedly due under section 502(a)(1)(B) of the
federal statute. Congress enacted ERISA to create “a
uniform regulatory regime over employee benefit plans.”
Aetna Health Inc. v. Davila, 542 U.S. 200, 208
(2004); see New Jersey Carpenters & the Trustees
Thereof v. Tishman Const. Corp. of New Jersey, 760 F.3d
297, 303 (3d Cir. 2014) (“Congress enacted ERISA to
ensure that benefit plan administration was subject to a
single set of regulations and to avoid subjecting regulated
entities to conflicting sources of substantive law.”).
To determine whether a state law claim is completely
preempted under Section 502(a), a court must determine that
(1) the plaintiff could have brought the action under Section
502(a) of ERISA and (2) no independent legal duty supports
the plaintiff's claim. Pascack Valley Hosp. v. Local
464A UFCW Welfare Reimbursement Plan, 388 F.3d 393, 400
(3d Cir. 2004); see also Davila, 542 U.S.
at 210 (holding that state law claim is completely preempted
when action could have been brought under Section
502(a)(1)(B) and no other legal duty independent of ERISA
may be brought under Section 502(a) of ERISA by a participant
or beneficiary “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);
see also Pilot Life Ins. Co. v. Dedeaux,
481 U.S. 41, 53 (1987). In determining whether a
plaintiff's state law claims “are predicated on a
legal duty that is independent of ERISA, ” Pascack
Valley, 388 F.3d at 393, a court “must examine
whether interpretation or application of the terms and scope
of the ERISA insurance plan form an ‘essential
part' of Plaintiff's claims.” North Jersey
Brain & Spine Ctr. v. Conn. Gen. Life Ins. Co., No.
10-4260, 2011 WL 4737067, at *6 (D.N.J. June 30, 2011). Thus,
this prong often turns on whether a plaintiff's claims
are “inextricably intertwined with the interpretation
and application of ERISA plan coverage and benefits.”
Id. at *7.
case, Plaintiff claims that it received valid assignments and
has brought ERISA claims pursuant to the assignments.
Therefore, Plaintiff's claim could be brought pursuant to
Section 502(a). Indeed, whether Plaintiff has a right to
recover depends entirely on interpretation of terms and
provisions of the ERISA plan. There is no independent basis
for Plaintiff's claim for benefits. “[C]ourts
routinely preempt state common law claims like the one
raised here that involve denial of benefits under an
ERISA-governed plan.” Advanced Orthopedics &
Sports Medicine Institute v. Empire Blue Cross
Blue Shield, Civ. No. 17-8697, 2018 WL 2758221, *7
(D.N.J. June 7, 2018). See also Cohen v. Horizon Blue
Cross Blue Shield of New Jersey, Civ. No.
15-4525, 2017 WL 685101, *6-7 (D.N.J. Feb. 21, 2017) (finding
claim of violation of New Jersey emergency services
regulation at N.J. Admin. Code § 11:24-5.3 completely
preempted). Accordingly, Count One is preempted by ERISA and
must be dismissed.
Count One was not preempted by ERISA, it still must be
dismissed because N.J. Admin. Code. § 11:4-37.3 does not
provide a private right of action. See R.J. Gaydos Ins.
Agency, Inc. v. Nat'l Consumer Ins. Co., 773 A.2d
1132, 1144 (N.J. 2001) (“New Jersey courts have
generally declined to infer a private right of action in
statutes where the statutory scheme contains civil penalty
To determine if a statute confers an implied private right of
action, courts consider whether: (1) plaintiff is a member of
the class for whose special benefit the statute was enacted;
(2) there is any evidence that the Legislature intended to
create a private right of action under the statute; and (3)
it is consistent with the underlying purpose of the
legislative scheme to infer the existence of such a remedy.
Id. at 1143. “The Court considers the same
factors to determine if an administrative regulation confers
an implied private right of action.” N.J.
Thoroughbred Horsemen's Ass'n v. Alpen House
U.L.C., 942 F.Supp.2d 497, 504 (D.N.J. 2013) (citing
Jalowiecki v. Leuc, 440 A.2d 21, 25-26 (
N.J.Super.Ct.App.Div. 1981)). There is no indication that the
New Jersey Legislature intended to create a private right of
action under § 11:4-37.3. See N.J. Thoroughbred
Horsemen's, 942 F.Supp.2d at 504-05; R.J. Gaydos
Ins. Agency, Inc., 773 A.2d at 1148 (“refusing to
recognize implied private cause of action against insurance
company in light of comprehensive regulation of insurance
industry”). Rather, New Jersey's Commissioner of
Insurance possesses the exclusive power to enforce the
regulation and impose penalties in the case of violations.
Therefore, Count One will be dismissed.
Count Three seeking ERISA plan benefits will be dismissed
because it fails to satisfy fundamental pleading
requirements. Specifically, the Complaint does not identify
facts such as the dates upon which services were rendered for
each patient, the nature of the services provided to each
patient, the amounts charged to each patient, the terms of
the assignments of benefits, the ...