United States District Court, D. New Jersey
Michael Vazquez, U.S.D.J.
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,  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.
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
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.
Party Signature: A.A.
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.
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.
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).