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E. Coast Aesthetic Surgery, P.C. v. UnitedHealthcare

United States District Court, D. New Jersey

June 28, 2018



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

         Plaintiff 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 GRANTED.

         I. BACKGROUND

         Plaintiff, 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.

         After 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.

         Defendant 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.

         Plaintiff 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.


         When a 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).

         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). 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.” Id.


         Defendant 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 herein.

         Britto Decl., Ex. A (PETER E. 000069), Ex. B (CAMELIA A. 000103), Ex. C (CAMELIA A. 000236) (emphasis added).[1] 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 ...

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