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E. Coast Advanced Plastic Surgery v. Aetna, Inc.

United States District Court, D. New Jersey

June 20, 2018

AETNA, INC., et al.,, Defendants.


          WILLIAM J. MARTINI, U.S.D.J.

         Plaintiff East Coast Advanced Plastic Surgery (“Plaintiff”) asserts breach of contract and related claims against Defendants Aetna, Inc. (“Aetna”), County of Essex (“Essex County”), and other fictitious individuals and entities, based on Aetna's refusal to make full payment on Plaintiff's claims for medical services provided to an Aetna member (“CH”). This matter comes before the Court on Plaintiff's motion to remand and Aetna's motion to dismiss. There was no oral argument. Fed.R.Civ.P. 78(b). For the reasons below, Plaintiff's motion to remand is DENIED and Aetna's motion to dismiss is GRANTED in part and DENIED in part.

         I. BACKGROUND

         Plaintiff is a healthcare provider based in Essex County, New Jersey. Notice of Removal, Ex. 1, Compl. ¶ 1, ECF No. 1-1 (“Compl.”). Aetna is a Pennsylvania corporation with its principal place of business in Hartford, Connecticut. Notice of Removal ¶ 4, ECF No. 1; Compl. ¶ 5. At all relevant times, Essex County provided CH an employer-sponsored Aetna health benefits plan (the “Plan”). At all relevant times, CH participated in the Plan, which Aetna administered. Id. ¶¶ 5, 9. And at all relevant times, Plaintiff was a non-participating or out-of-network provider who had no contract with Aetna. Id. ¶ 15.

         Through a course of dealing as to CH, Plaintiff alleges Aetna provided pre-authorization letters to indicate the Plan would cover Plaintiff's medical services. Id. ¶¶ 20, 29. Plaintiff relied on and understood Aetna's letters as promises to pay for the pre-authorized procedures. Id. ¶¶ 40, 46, 57-58. To Plaintiff's detriment, Aetna paid only a fraction of the amount billed or the amount it was required to pay under the Plan's terms. Id. ¶¶ 34-36, 47. Plaintiff now seeks to recover the outstanding balance, which it contends is the usual, customary, reasonable, and fair value for its medical services.

         Plaintiff filed a complaint against Defendants in New Jersey state court, alleging (1) breach of contract, (2) promissory estoppel, (3) account stated, and (4) fraudulent inducement. Compl. ¶¶ 38-61. Aetna then removed the case here, based on diversity jurisdiction. Notice of Removal ¶ 2. But Plaintiff seeks remand, arguing Aetna failed to obtain Essex County's consent for removal. See Pl.'s Remand Mem. of Law 1-3, ECF No. 7-1. Aetna opposes, arguing Plaintiff fraudulently joined Essex County in an apparent attempt to defeat diversity jurisdiction and, in any case, Essex County is a nominal party here with no real interest at stake. Def.'s Remand Opp'n Br. 1-18, ECF No. 10. In reply, Plaintiff argues Essex County is financially responsible for claims made under the Plan and that state law alone governs here, the latter point Aetna never disputed. See Pl.'s Remand Reply Mem. of Law 2-10, ECF No. 12.

         While the remand motion was pending, Aetna moved to dismiss, arguing the pre-authorization letters in no way created an implied-in-fact contract that compelled paying Plaintiff the full amount charged for its services. That would defeat the breach of contract and promissory estoppel claims. See Def.'s Mot. to Dismiss Mem. of Law 7-12, ECF No. 8-1. Aetna then argues the fraud claim fails to meet heightened pleading requirements and is otherwise barred by the economic loss doctrine. Id. at 12-15. Finally, with no agreement as to the amount owed, Aetna finds Plaintiff's account stated claim deficient. Id. at 16.

         Plaintiff opposes, without citing a single case, statute, or other legal authority. Plaintiff argues an implied-in-fact contract arose when Aetna issued the pre-authorization letters. And it was those pre-authorization letters that created a clear and definite promise to pay Plaintiff the usual and customary value for its medical services. See Pl.'s Mot. to Dismiss Opp'n Br. 3-5, ECF No. 9. Plaintiff then grounds its account stated claim in Aetna's refusal to pay the invoiced amount. Id. at 5. As to the fraud claim, Plaintiff contends it has pleaded with requisite specificity. Id. at 6.

         Aetna filed a reply, reiterating that the pre-authorization letters only confirmed CH's eligibility for coverage under the Plan and in no way represented a promise to pay, especially at the rate Plaintiff billed. Def.'s Mot. to Dismiss Reply Br. 1-2, ECF No. 11.


         On a motion to remand, “[t]he removing party . . . carries a heavy burden of showing that at all stages of the litigation the case is properly before the federal court. Removal statutes are to be strictly construed, with all doubts to be resolved in favor of remand.” Brown v. Jevic, 575 F.3d 322, 326 (3d Cir. 2009) (citations omitted). In actions raising only state law claims, federal courts have subject matter jurisdiction when the dispute satisfies the amount in controversy requirement and no plaintiff resides in the same state as any defendant. See In re Briscoe, 448 F.3d 201, 215 (3d Cir. 2006) (citation omitted).

         Federal Rule of Civil Procedure 12(b)(6) allows dismissing 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, 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). And a court will usually consider documents filed with the complaint, such as those integral to or explicitly relied upon in the complaint.” Schmidt v. Skolas, 770 F.3d 241, 249 (3d Cir. 2014) (emphasis in original) (internal quotation marks and citations omitted).

         Although 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.” Iqbal, 556 U.S. at 687.

         III. ...

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