United States District Court, D. New Jersey
MICHAEL J. SMIKUN, DANIEL C. NOWAK LAW OFFICES OF SEAN R.
CALLAGY, ESQ On behalf of Plaintiff
MICHAEL E. HOLZAPFEL BECKER LLC On behalf of Defendant.
L. HILLMAN, U.S.D.J.
one of many ERISA suits filed by Plaintiff Dr. Rahul Shah, as
purported assignee of his individual patients, against his
patients' various insurance companies. In each suit,
Plaintiff asserts that the insurance companies wrongfully
denied requests for payment of benefits under the
patients' health insurance policies, and consequently,
Plaintiff's bills for service were not paid, or not fully
the Court is Defendant's Motion for Summary Judgment. For
the reasons that follow, Defendant's motion will be
Court takes its facts from Defendant's Statement of
Undisputed Material Facts and Plaintiff's Response. On
October 28, 2013, Plaintiff performed a spinal surgery on
Monica M. (“Patient”). At the time of the
surgery, Patient had health coverage through a self-funded
ERISA welfare benefit plan (“DTZ Plan”),
sponsored by her employer. To receive coverage under the
plan, the procedure must be “medically necessary and
appropriate, ” as determined by Defendant. Plaintiff
does not participate with Blue Cross which administers the
Plan and is accordingly considered an out-of-network
Patient's surgery, Plaintiff submitted $322, 850 in
charges to Defendant for out-of-network reimbursement. The
claim was denied because the surgery was determined to not be
medically necessary and appropriate. This decision was upheld
on Plaintiff's administrative appeal.
out-of-network provider, Plaintiff asserts derivative, rather
than direct, standing to assert the claims pleaded in the
Complaint. Plaintiff relies on an “Assignment of
Benefits & Ltd. Power of Attorney & Medical Records
Authorization” purportedly given by Patient to
Plaintiff and a “Christian Brenner, PA-C” on
March 27, 2014. Notably, the DTZ Plan expressly prohibits
Complaint asserted four claims: (1) breach of contract; (2)
denial of benefits in violation of § 1332(a)(1)(B); (3)
breach of fiduciary duty in violation of §
1332(a)(3)(B); and (4) failure to maintain a reasonable
claims process pursuant to 29 C.F.R. 2560.503-1. Following a
motion to dismiss by Defendant, this Court dismissed as moot
Count One pursuant to Federal Rule of Civil Procedure 41(a)
and Count Four. Defendant filed its Motion for Summary
Judgment on September 29, 2017.
Court has federal question subject matter jurisdiction
pursuant to 28 U.S.C. § 1331.
judgment is appropriate where the Court is satisfied that
“'the pleadings, depositions, answers to
interrogatories, and admissions on file, together with the
affidavits if any,' . . . demonstrate the absence of a
genuine issue of material fact” and that the moving
party is entitled to a judgment as a ...