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University Spine Center v. Cigna Health and Life Insurance Co.

United States District Court, D. New Jersey

August 29, 2018

UNIVERSITY SPINE CENTER on assignment of Minerva L., Plaintiff,
v.
CIGNA HEALTH AND LIFE INSURANCE COMPANY, Defendant.

          OPINION

          KEVIN MCNULTY UNITED STATES DISTRICT JUDG

         This is 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 without prejudice.

         I. The Complaint

         The 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:

         University is a medical services provider. CHLIC is a third-party claims administrator.

         On 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)

         University, 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)

         University 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)

         The 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. § 1105(a)

         II. Standard on a Motion to Dismiss

         Fed. R. 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).

         Fed. R. 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 Twombly, ...


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