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Lourdes Specialty Hospital of Southern New Jersey v. H.D. Supply, Inc. Health and Welfare Program

United States District Court, D. New Jersey

August 10, 2018

LOURDES SPECIALTY HOSPITAL OF SOUTHERN NEW JERSEY, on assignment of Timothy W., Plaintiff,
v.
H.D. SUPPLY, INC. HEALTH AND WELFARE PROGRAM, Defendant.

          MICHAEL J. SMIKUN MICHAEL GOTTLIEB CALLAGY LAW, PC 650 FROM ROAD SUITE, On behalf of Plaintiff.

          JAMES P. ANELLI, DANITA C. MINNIGAN, LECLAIRRYAN, ONE RIVERFRONT PLAZA On behalf of Defendant.

          OPINION

          NOEL L. HILLMAN, U.S.D.J.

         This is an ERISA suit concerning Defendant H.D. Supply, Inc. Health and Welfare Program's alleged failure to properly reimburse Plaintiff Lourdes Specialty Hospital of Southern New Jersey for medical services provided by Plaintiff. Before the Court is Defendant's Motion to Dismiss. For the reasons that follow, Defendant's motion will be granted.

         I.

         The Court takes its facts from Plaintiff's November 10, 2017 Complaint. Timothy W. (“Patient”) underwent treatment in Plaintiff's long-term acute care facility. Patient has an insurance plan with Defendant. A representative of Defendant verified Patient's insurance with Plaintiff. Plaintiff obtained an assignment of benefits from Patient, which Plaintiff alleges enables it to bring this ERISA claim. Pursuant to this assignment, Plaintiff submitted a Health Insurance Claim Form in connection with Patient's treatment.

         Patient's first stay at the facility took place from September 15, 2014 through October 27, 2014. Patient's second stay took place from March 19, 2015 to May 29, 2015. Patient's first stay was divided into three separate billing cycles; Patient's second stay was divided into four billing cycles. Plaintiff's total charges for the first billing cycle of Patient's first stay were $169, 160.50. Defendant issued payment in the amount of $123, 031.81. Plaintiff pleads Defendant's payment for Patient's first cycle of treatment “is consistent with the rates promised during the insurance verification process.”

         Plaintiff pleads that for the subsequent billing cycles, “Defendant reimbursed Plaintiff substantially less than what was promised during the insurance verification process and a substantially lower percentage of usual and customary charges than what was remitted for the first billing cycle.” For instance, Plaintiff's charges for the second billing cycle of Patient's first stay were $178, 541.29, but Defendant paid $22, 797.83. As to the first billing cycle of Patient's second stay, Plaintiff's charges were $188, 432.05, but Defendant paid $22, 589.32. As to the second billing cycle of Patient's second stay, Plaintiff's total charges were $184, 079.32, but Defendant paid $26, 717.13. As to the third billing cycle of Patient's second stay, Plaintiff's total charges were $184, 832.89, but Defendant paid $13, 220.09. As to the fourth billing cycle of Patient's second stay, Plaintiff's charges were $324, 962.93, but Defendant paid $36, 652.08.

         While Plaintiff submitted appeals, Defendant did not remit any additional payments. Plaintiff pleads Defendant's reimbursement amounts to an underpayment of $1, 110, 106.20 based on the terms of the insurance plan.

         Plaintiff's November 10, 2017 Complaint asserts two claims: (1) failure to make all payments under 29 U.S.C. § 1132(a)(1)(B) and (2) breach of fiduciary duty and co-fiduciary duty under 29 U.S.C. §§ 1132(a)(3), 1104(a)(1), and 1105(a). Defendant filed a Motion to Dismiss on January 22, 2018.

         II.

         This Court has federal question jurisdiction pursuant to 28 U.S.C. § 1331.

         III.

         When considering a motion to dismiss a complaint for failure to state a claim upon which relief can be granted pursuant to Federal Rule of Civil Procedure 12(b)(6), a court must accept all well-pleaded allegations in the complaint as true and view them in the light most favorable to the plaintiff. Evancho v. Fisher, 423 F.3d 347, 351 (3d Cir. 2005). It is well settled that a pleading is sufficient if it contains ...


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