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Shah v. Horizon Blue Cross Blue Shield of New Jersey

United States District Court, D. New Jersey

July 13, 2018

RAHUL SHAH on assignment of EDWARD H., Plaintiff,
v.
HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY and BLUE CROSS BLUE SHIELD OF MINNESOTA, Defendants.

          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

          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. 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.

         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 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.

         Plaintiff 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.

         In addition, the Plan sets forth the following anti-assignment clause:

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 obligation.

         It further provides:

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 else.

         It also 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 ...

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