United States District Court, D. New Jersey
LOURDES SPECIALTY HOSPITAL OF SOUTHERN NEW JERSEY, on assignment of Timothy W., Plaintiff,
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.
P. ANELLI, DANITA C. MINNIGAN, LECLAIRRYAN, ONE RIVERFRONT
PLAZA On behalf of Defendant.
L. HILLMAN, U.S.D.J.
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.
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
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.”
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
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.
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.
Court has federal question jurisdiction pursuant to 28 U.S.C.
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