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University Spine Center v. Cigna Health and Life Insurance Company

United States District Court, D. New Jersey

August 8, 2018

UNIVERSITY SPINE CENTER, a/o/a Asmma A., Plaintiff,
v.
CIGNA HEALTH AND LIFE INSURANCE COMPANY, Defendant.

          OPINION

          John Michael Vazquez, U.S.D.J.

         This case involves a reimbursement dispute between a surgical practice and the healthcare insurance administrator. Plaintiff University Spine Center ("University Spine" or "Plaintiff), as an assignee of a patient who received surgical treatment at Plaintiffs facility, brings suit against Defendant CIGNA Health and Life Insurance Company ("CIGNA" or "Defendant"). Plaintiff claims that Defendant failed to reimburse the full amount of the medical services provided to the patient. Currently before the Court is Defendant's motion to dismiss pursuant to Federal Rule of Civil Procedure 12(b)(6). D.E. 7. The Court reviewed the submissions in support and in opposition, [1] and considered the motions without oral argument pursuant to Fed.R.Civ.P. 78(b) and L. Civ. R. 78.1 (b). For the reasons stated below, Defendant's motion to dismiss is GRANTED in part and DENIED in part.

         I. FACTUAL BACKGROUND[2]

         Plaintiff University Spine is a healthcare provider in New Jersey. Compl. at ¶ 1. On October 10, 2011, Asmma A. ("A.A.") underwent L3 and L4 laminectomies and a resection of an intradural extramedullary lesion at Plaintiffs facility. Id. at ¶¶ 4-5; Ex. A. A.A. also signed an assignment of benefits ("AOB") form. Id. at ¶ 6. The AOB form provides, in relevant part:

I, the undersigned, certify that I (or my dependent/s) have insurance coverage withand assign directly to University Spine Center, Arash Emani MD, Ki Soo Hwang MD, Kumar Sinha MD, Michelle Brenner NP 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 submissions.

         Responsible Party Signature: A.A.

         Relationship: __________

         Dated: ________

         Compl., Ex. B.

         Defendant is the claims administrator for A.A.'s health care plan. Id. at ¶ 12. Pursuant to the AOB, Plaintiff prepared Health Insurance Claim Forms ("HICFs") demanding reimbursement in the amount of $112, 730.00 from Defendant for medically necessary and reasonable services rendered to A.A. Id. at ¶ 7. Defendant paid a total of $2, 339.48. Id. at ¶ 8. Plaintiff then engaged in the "applicable administrative appeals process maintained by Defendant." Id. at ¶ 9. Plaintiff also requested "among other things, a copy of the Summary Plan Description, Plan Policy, and identification of the Plan Administrator/Plan Sponsor." Id. at ¶ 10. Defendant failed to provide Plaintiff additional payment or the requested documents. Id. at ¶ 11. Plaintiff now sues for $110, 390.52, the amount it claims Defendant underpaid. Id. at ¶ 13.

         II. PROCEDURAL HISTORY

         On August 30, 2017, Plaintiff filed a Complaint in the Superior Court of New Jersey. D.E. 1. On October 9, 2017, Defendant filed a notice of removal. D.E. 1. The case was assigned to this Court on October 10, 2017. Defendant then filed the current motion. D.E. 7. Plaintiff submitted opposition, D.E. 11, to which Defendant replied, D.E. 14. Defendant submitted two notices of supplemental authority, D.E. 15, 16, to which Plaintiff replied, D.E. 19.

         Plaintiffs Complaint brings three counts: breach of contract (Count One), failure to make all payments pursuant to a member's plan under 29 U.S.C. § 1132(a)(1)(B) (codified as § 502(a)(1)(B)) (Count Two), and breach of fiduciary duty under 29 U.S.C. § 1132(a)(3) (codified as § 502(a)(3)), 1104(a)(1) (codified as § 404(a)(1)), and § 1105(a) (codified as § 405(a)) (Count Three).

         III. ...


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