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Shah v. Horizon Blue Cross Blue Shield of New Jersey

United States District Court, D. New Jersey

June 29, 2018

RAHUL SHAH on assignment of MONICA M., Plaintiff,
v.
HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY and BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, Defendants.

          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.

          OPINION

          NOEL L. HILLMAN, U.S.D.J.

         This is 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 paid.

         Before the Court is Defendant's Motion for Summary Judgment. For the reasons that follow, Defendant's motion will be granted.

         I.

         The 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 provider.

         After 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.

         As an 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 third-party assignments.

         Plaintiff's 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.[1]

         II.

         This Court has federal question subject matter jurisdiction pursuant to 28 U.S.C. § 1331.

         III.

         Summary 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 ...


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