United States District Court, D. New Jersey
MICHAEL J. SMIKUN, MICHAEL GOTTLIEB, 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. As in those other
suits, Plaintiff asserts in this matter that the insurance
company wrongfully denied a request for payment of benefits
under his patient's health insurance policy, and
consequently, Plaintiff's bills for service were not
paid, or not fully paid.
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
April 27, 2015, Plaintiff performed surgery on Edward H.
(“Patient”), during which he fused some of
Patient's cervical vertebrae. At the time of his surgery,
Patient had health coverage through a self-funded health
benefits plan sponsored and administrated by an employer
(“the Plan”). The Plan is an ERISA benefit plan.
Defendant Blue Cross Blue Shield of Minnesota is the Claims
Administrator for the Plan. Under the Plan, a person must be
an eligible employee, retiree, or an eligible dependent of
the employee to be entitled to receive Plan benefits.
is an out-of-network, nonparticipating provider.
Out-of-network, nonparticipating providers may submit claims
on behalf of the claimant. The Plan language explains that
the allowed amount for out-of-network providers is usually
less than the allowed amount for in-network providers. The
Plan also explains that use of an out-of-network provider can
result in significantly higher out-of-pocket expenses.
addition, the Plan sets forth the following anti-assignment
A claimant may not assign his or her benefits to an
Out-of-Network Nonparticipating Provider, except when parents
are divorced. In the case of divorce, the custodial parent
may request, in writing, that the Plan pay an Out-of-Network
Nonparticipating Provider for covered services for a child.
When the Plan pays the provider at the request of the
custodial parent, the Plan has satisfied its payment
If you have a claim for benefits which is denied or ignored,
in whole or in part, you may file suit in a state or federal
court . . .; however, you may not assign, convey, or in
any way transfer your right to bring a lawsuit to anyone
provides that “[a] claimant may not assign to any other
person or entity his or her right to legally challenge any
decision, action or inaction of the Claims
Administrator.” It further states:
The Plan benefits described in this Summary Plan Description
are intended solely for the benefit of you and your covered
dependents. No. person who is not a Plan participant or
dependent of a Plan participant may bring a legal or
equitable claim or cause of action pursuant to this Summary