United States District Court, D. New Jersey
UNIVERSITY SPINE CENTER on assignment of Minerva L., Plaintiff,
CIGNA HEALTH AND LIFE INSURANCE COMPANY, Defendant.
MCNULTY UNITED STATES DISTRICT JUDG
an action under the Employment Retirement Income Security Act
of 1974 ("ERISA"), 29 U.S.C. § 1001 et
seq. University Spine Center ("University"),
an out-of-network provider, sues as assignee of its patient,
"Minerva L." University alleges that it is owed
additional insurance reimbursement for medical services
provided. The claims administrator of the patient's
health benefit plan, defendant Cigna Health and Life
Insurance Company ("CHLIC"), moves under
Fed.R.Civ.P. 12(b)(6) to dismiss the Complaint for failure to
state a claim upon which relief may be granted. For the
reasons stated herein, I will grant the motion to dismiss
allegations of the complaint ("Cplt", ECF no. 1}
are taken as true for purposes of this motion. See
Section II, infra. They are as follows:
is a medical services provider. CHLIC is a third-party claims
March 23, 2015, 2015, University provided medical services to
Minerva L.-specifically, an anterior spinal discectomy and
fusion, as well as other surgery to the lumbar spine. (Cplt.
¶¶ 4-5) Minerva L. assigned her rights to payment
of benefits under her insurance plan, as well as her ERISA
rights, to University. (Id. ¶ 6)
an out-of-network provider, alleges "[u]pon information
and belief, [that] Defendant has failed to make payment
pursuant to the controlling Plan or Policy." (Cplt.
¶ 3) University prepared claim forms demanding
reimbursement in the amount of $195, 032 from defendant
CHLIC. CHLIC reimbursed University in die amount of $52,
045.41. (Id. ¶¶ 7-8) By University's
reckoning, after deductions, copayments and coinsurance, it
has been underpaid in the amount of $64, 973.79.
(Id. ¶ 13)
exhausted the administrative appeals process. (Id.
¶ 9) It requested copies of the Plan and identification
of the Plan Administrator/Plan Sponsor, but did not receive
them, (Id.¶¶ 10-11)
Complaint asserts two causes of action:
COUNT ONE - FAILURE TO MAKE ALL PAYMENTS PURSUANT TO
MEMBER'S PLAN UNDER 29 U.S.C. § 1132(a)(1)(B); and
COUNT TWO - BREACH OF FIDUCIARY DUTY UNDER 29 U.S.C. §
1132(a)(3), 29 U.S.C. § 1104(a)(1), and 29 U.S.C. §
Standard on a Motion to Dismiss
Civ. P. 12(b)(6) provides for the dismissal of a complaint,
in whole or in part, if it fails to state a claim upon which
relief can be granted. The moving party bears the burden of
showing that no claim has been stated. Hedges v. United
States, 404 F.3d 744, 750 (3d Cir. 2005). In deciding a
motion to dismiss, a court must take all allegations in the
complaint as true and view them in the light most favorable
to the plaintiff. See Warth v. Seldin, 422 U.S. 490,
501 (1975); Trump Hotels & Casino Resorts, Inc. v.
Mirage Resorts Inc., 140 F.3d 478, 483 (3d Cir. 1998);
see also Phillips v. County of Allegheny, 515 F.3d
224, 231 (3d Cir. 2008) ("reasonable inferences"
principle not undermined by later Supreme Court
Twombly case, infra).
Civ. P. 8(a) does not require that a complaint contain
detailed factual allegations. Nevertheless, "a
plaintiffs obligation to provide the •grounds' of
his 'entitlement to relief requires more than labels and
conclusions, and formulaic recitation of the elements of a
cause of action will not do." Bell All Corp. v.
Twombly,550 U.S. 544, 555 (2007). Thus, the factual
allegations must be sufficient to raise a plaintiffs right to
relief above a speculative level, such that it is
"plausible on its face." See Id. at 570;
see alsoUmland v. PLANCO Fin. Serv., Inc.,542 F.3d 59, 64 (3d Cir. 2008). A claim has "facial
plausibility when the plaintiff pleads factual content that
allows the court to draw the reasonable inference that the
defendant is liable for the misconduct alleged."
Ashcroft v. Iqbal,556 U.S. 662, 678 (2009) (citing