United States District Court, D. New Jersey
MCNULTY United States District Judge
University Spine Center (alternatively, “the
Center”), brings this ERISA action “on assignment
of Kim W., ” its patient. The Complaint alleges that
Kim W.'s insurer, Anthem Blue Cross Blue Shield
(“Anthem BCBS”), did not provide appropriate
reimbursement for medical services provided to Kim W. by the
Center. Now before the court is Anthem BCBS's motion to
dismiss the complaint. Anthem BCBS argues that the Center
lacks standing to sue and that its Complaint fails to state a
claim on which relief can be granted.
for purposes of this motion to dismiss, the allegations of
the complaint are assumed to be true and all inferences are
drawn in favor of the plaintiff.
University Spine Center is a health care provider in Passaic,
New Jersey. (Compl. ¶ 1). Defendant Anthem BCBS is
primarily in the business of providing and administering
health plans or policies. (Compl. ¶ 2). Anthem BCBS
engages in significant business in New Jersey. (Compl. ¶
October 22, 2015, University Spine Center provided medically
necessary and reasonable services to Kim W. (referred to
herein as “Patient”) (Compl. ¶ 4). Patient
underwent revision lumbar laminectomies, repair of dural
tear, posterior spinal fusion, posterior interbody fusion,
application of mechanical cage, posterior segmental
instrumentation using pedicle screws, and other related
procedures. (Compl. ¶ 5).
Spine Center obtained an “Assignment and Release”
from Patient, which enabled the Center to bring this action
under the Employee Retirement Income Security Act of 1974, 29
U.S.C. § 1002, et seq. (“ERISA”).
(Compl. ¶ 6). The “Assignment and Release”
provides as follows:
I, the undersigned, certify that I (or my dependent/s) have
coverage withand assign directly to University Spine Center,
all insurance benefits, if any, otherwise payable to me for
the services rendered. I understand that I am financially
responsible for all charges, whether or not paid by
insurance. I hereby authorize the doctor to release all
information necessary to secure the payment of benefits. I
authorize the use of this signature on all insurance
(Compl. ex. B). Pursuant to that assignment of benefits, the
Center prepared and submitted to Anthem BCBS certain Health
Insurance Claim Forms (“HICFs”) formally
demanding reimbursements totaling $196, 448.00 for the
services rendered to Patient. (Compl. ¶ 7). Anthem BCBS
reimbursed the Center for $17, 582.26. (Compl. ¶ 8).
University Spine Center engaged in Anthem BCBS's
administrative appeals process and also requested from Anthem
BCBS the summary plan description, plan policy, and
identification of the plan administrator or plan sponsor.
(Compl. ¶¶ 9-10).
BCBS did not remit the total payment demanded and also did
not produce the requested documents or information. (Compl.
¶ 11). The Center alleges that Anthem BCBS underpaid by
$178, 865.74. (Compl. ¶ 13).
Center's Complaint asserts two causes of action:
Count 1 asserts a claim for alleged underpayment under ERISA
§ 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B). (Compl.
Count 2 asserts a claim for breach of fiduciary duty under
ERISA §§ 404(a)(1), 405(a), 502(a)(3), 29 U.S.C.
§§ 1104(a)(1), 1105(a), 1132(a)(3). (Compl.
Spine Center seeks $178, 865.74 in damages, plus interest,
attorneys' fees, and costs of suit, as well as any other
appropriate relief. Now before the court is Anthem BCBS's
motion to dismiss the complaint. (ECF No. 8).
Rule 12(b)(1) Standard
to dismiss for lack of subject matter jurisdiction pursuant
to Federal Rule of Civil Procedure 12(b)(1) may be raised at
any time. Iwanowa v. Ford Motor Co., 67 F.Supp.2d
424, 437-38 (D.N.J. 1999). Such Rule 12(b)(1) challenges may
be either facial or factual attacks. See 2
Moore's Federal Practice § 12.30 (3d ed. 2007);
Mortensen v. First Fed. Sav. & Loan Ass'n,
549 F.2d 884, 891 (3d Cir. 1977). A facial challenge asserts
that the complaint does not allege sufficient grounds to
establish subject matter jurisdiction. Iwanowa, 67
F.Supp.2d at 438. “In reviewing a facial attack, the
court must only consider the allegations of the complaint and
documents referenced therein and attached thereto, in the
light most favorable to the plaintiff.” Lincoln
Ben. Life Co. v. AEI Life, LLC, 800 F.3d 99, 105 (3d
Cir. 2015) (citing Gould Elecs. Inc. v. United
States, 220 F.3d 169, 176 (3d Cir. 2000)). The standard
on a facial attack, then, is similar to the one that would
govern an ordinary Rule 12(b)(6) motion.
BCBS alleges, based on the allegations of the Complaint and
attached exhibits, that the assignment from Patient to the
Center does not create standing. That is a facial challenge
to standing, and it is properly analyzed under a Rule