United States District Court, D. New Jersey
E. COAST AESTHETIC SURGERY, P.C. o/a/o CAMELIA A., LEONARD C., and PETER E.,, Plaintiff,
WILLIAM J. MARTINI, U.S.D.J.
East Coast Aesthetic Surgery, P.C., on assignments of Camelia
A., Leonard C., and Peter E. (“Patients”), filed
suit against Defendant UnitedHealthcare, seeking to recover
the entirety of payment for services rendered under the
Employee Retirement Income Security Act of 1974
(“ERISA”) and New Jersey state law. Defendant
moves to dismiss under Federal Rule of Civil Procedure
12(b)(6). This Court has jurisdiction under 28 U.S.C.
§§ 1331, 1376 and decides the matter without oral
argument. Fed.R.Civ.P. 78(b). For the reasons stated herein,
Defendant's motion to dismiss is
as assignee, seeks reimbursement of underpaid benefits from
Defendant over emergency medical services rendered to
Patients. Compl. ¶¶ 3-10, 18, ECF No. 1. At all
relevant times, Patients were beneficiaries in
Defendant's ERISA-governed insurance plans (the
“Plans”). Id. ¶¶ 3, 5;
see Decl. of Maryann Britto ¶¶ 1-5, ECF
No. 11-1 (“Britto Decl.”); Decl. of Mabel Suzanne
Fairley ¶¶ 1-5, ECF No. 11-5 (“Fairley
Decl.”). And at all relevant times, Plaintiff was an
out-of-network healthcare provider that had no contract with
Defendant. Compl. ¶ 13.
exhausting its administrative appeals, Plaintiff filed suit,
bringing a claim for failure to comply with emergency cost
sharing under New Jersey Administrative Code § 11:4-37.3
(Count One), id. ¶¶ 11-14, as well as two
ERISA-based claims for failure to make all payments under a
member's plan under 29 U.S.C. § 1132(a)(1)(B) (Count
Two), id. ¶¶ 15-22, and breach of
fiduciary and co-fiduciary duties under 29 U.S.C.
§§ 1132(a)(3), 1104(a)(1), and 1105(a) (Count
Three), id. ¶¶ 24-31.
moves to dismiss, arguing Plaintiff lacks standing to plead
its ERISA benefit claim because the Plans contain valid and
enforceable anti-assignment clauses. See Def.'s
Mem. of Law 16-19, ECF No. 11-8. Defendant also argues
Plaintiff's breach of fiduciary duty claim is duplicative
of its benefits claim. Id. at 19-20. Lastly,
Defendant argues ERISA preemption applies to Plaintiff's
state law claim and, in any event, the regulation forming the
basis for the claim provides no private right of action.
Id. at 10- 16.
opposes with a litany of arguments as to standing, despite
the Plans' anti-assignment clause language. See
Pl.'s Opp'n Br. 13-25, ECF No. 17; Pl.'s
Sur-Reply Letter 1-2, ECF No. 24. Plaintiff then argues its
state law claim survives ERISA preemption and that the
regulation allows private party suits. See Id. at
8-13. Defendant filed a reply, essentially restating its
original arguments. See Def.'s Reply Mem. of
Law, ECF No. 9.
defendant challenges a plaintiff's standing to allege an
ERISA claim, courts generally apply the Rule 12(b)(6)
standard, which provides for dismissing a complaint, in whole
or in part, if the plaintiff fails to state a claim upon
which relief can be granted. See N. Jersey Brain &
Spine Ctr. v. Aetna, Inc., 801 F.3d 369, 371 n.3 (3d
Cir. 2015) (citations omitted). The moving party bears the
burden to show no claim has been stated. Hedges v. United
States, 404 F.3d 744, 750 (3d Cir. 2005) (citation
omitted). “To decide a motion to dismiss, courts
generally consider only the allegations contained in the
complaint, exhibits attached to the complaint, and matters of
public record[, ]” including “a document
integral to or explicitly relied upon in the
complaint . . . .” Schmidt v. Skolas, 770 F.3d
241, 249 (3d Cir. 2014) (emphasis in original) (quotation
marks and citations omitted).
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). 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). In other
words, a plaintiff must “plead 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)
(Twombly, 550 U.S. at 570). While “[t]he
plausibility standard is not akin to a ‘probability
requirement,' . . . it asks for more than a sheer
possibility that a defendant has acted unlawfully.”
challenges Plaintiff's standing to bring the ERISA claims
based on the anti-assignment clauses found in the Plans'
documents, limiting Patients from assigning their benefits.
See Def.'s Mem of Law at 4-7, 16-19. As to Peter
E. and Camelia A.'s Plans, the anti-assignment clauses
read as follows:
This Certificate is not assignable by Group without Our
written consent. Any benefits under this
Certificate are not assignable by any Member
without Our written consent. In
addition, This Agreement shall not confer any rights or
obligations on third parties except as specifically provided
Decl., Ex. A (PETER E. 000069), Ex. B (CAMELIA A. 000103),
Ex. C (CAMELIA A. 000236) (emphasis added). And as to Leonard
C.'s Plan, the relevant anti-assignment clause provides
that: “Coverage may be assigned only with
the consent of [United HealthCare ...