United States District Court, D. New Jersey
IJKG OPCO LLC, d/b/a CAREPOINT HEALTH-BAYONNE MEDICAL CENTER, Plaintiff,
GENERAL TRADING COMPANY, CONSOLIDATED HEALTH PLANS INC., CIGNA CORPORATION, INC., ZELIS HEALTHCARE, INC. a/k/a PREMIER HEALTH EXCHANGE, INC., FIRST CHOICE INSURANCE SERVICES, L.L.C., and STANDARD SECURITY LIFE INSURANCE COMPANY OF NEW YORK, Defendants.
McNulty, United States District Judge.
plaintiff, IJKG Opco LLC, doing business as CarePoint
Health-Bayonne Medical Center ("BMC"), brings suit
to recover the costs of medical care it provided to
"Patient 1," who experienced severe renal
complications and was hospitalized for about three weeks. The
defendants named in the Amended Complaint are General
Trading Company ("General Trading"), which provided
the patient's employee welfare benefits plan; Cigna
Corporation Inc. ("Cigna");Consolidated Health Plans,
Inc. ("CHP"), which was a third-party administrator
for the plan; Zelis Healthcare, Inc. ("Zelis"),
also known as Premier Health Exchange, Inc. or PHX, which was
the claims contract negotiator; and Standard Security Life
Insurance Company of New York ("SS Life"), which
provided General Trading with a stop-loss policy that insured
losses in excess of a deductible arising from specific plan
already granted a motion to dismiss the Amended Complaint
filed by defendant SS Life, and denied motions to dismiss or
for judgment on the pleadings filed by General Trading and
Zelis. (See Opinion ("Op."), ECF no. 122,
as amended by Order, ECF no. 133.) Now before the court are
motions for judgment on the pleadings pursuant to
Fed.R.Civ.P. 12(c), brought by CHP (ECF no.
and Cigna (ECF no. 105). For the reasons stated herein,
CHP's motion is denied, and Cigna's motion is
Summary of Facts
incorporate by reference the summary of the allegations of
the Amended Complaint from my prior Opinion. (ECF no. 122) I
state only a few of the most pertinent allegations here.
November 2013, Patient 1 received treatment for a kidney
ailment at BMC. The bill was $771, 191.58. General Trading,
whose self-funded employee welfare benefits plan provides
coverage to Patient 1, reimbursed BMC for only $175, 358.05
of that total.
General Trading's claim processor, issued an explanation
of benefits on January 29, 2014, which provided reasons for
disallowed charges. (Id. ¶ 28.) The majority of
disallowances were labeled as "discount . . . negotiated
through Premier Healthcare Exchange" or "[e]xceeds
reasonable and customary charge." (Id.) On
November 28, 2014, BMC filed an appeal with CHP.
(Id. ¶ 30.) CHP denied the appeal in its
entirety and directed BMC to balance-bill for the outstanding
January 13, 2015, BMC filed a second-level appeal with CHP.
(Id. ¶ 31.) By letter dated February 23, 2015,
that appeal was denied. (Id. ¶ 32.)
sues to recover the unreimbursed balance of its bill, in the
amount of $595, 833.53. Count One of the Amended Complaint
claims that defendants General Trading and Cigna violated
§ 502(a)(1)(B) of the Employee Retirement Income
Security Act of 1974 ("ERISA"), 29 U.S.C. §
1132(a)(1)(B), et seq., by underpaying the claim.
(AC HI 47-61) Count Two is a claim under ERISA §
502(a)(3), 29 U.S.C. § 1132(a)(3), that defendants
General Trading, Cigna, CHP, and Zelis (PHX) breached their
fiduciary duties to Patient 1. (AC ¶¶ 62-73) Count
Three is a claim under ERISA § 502(a)(3) that the same
four defendants denied BMC full and fair review of the claim,
in violation of ERISA § 503. (AC ¶¶
Standard of Review
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 defendants, as the moving parties, bear
the burden of showing that no claim has been stated.
Animal Science Prods., Inc. v. China Minmetals
Corp., 654 F.3d 462, 469 n.9 (3d Cir. 2011). For the
purposes of a motion to dismiss, the facts alleged in the
complaint are accepted as true and all reasonable inferences
are drawn in favor of the plaintiff. N.J. Carpenters
& the Trustees Thereof v. Tishman Const. Corp. of
N.J., 760 F.3d 297, 302 (3d Cir. 2014).
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 a formulaic recitation of the elements of a
cause of action will not do." Bell Atl. Corp. v.
Twombly, 550 U.S. 544, 555 (2007). Thus, the
complaint's factual allegations must be sufficient to
raise a plaintiffs right to relief above a speculative level,
so that a claim is "plausible on its face."
Id. at 570; see also W. Run Student Housing
Assocs., LLC v. Huntington Nat Bank, 712 F.3d 165, 169
(3d Cir. 2013). That facial-plausibility standard is met
"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, 550 U.S. at 556). While "[t]he
plausibility standard is not akin to a 'probability
requirement'. . . it asks for more than a sheer
possibility." Iqbal, 556 U.S. at 678.
12(c) motion for judgment on the pleadings is often
indistinguishable from a motion to dismiss, except that it is
made after the filing of a responsive pleading. Fed.R.Civ.P.
12(h)(2) "provides that a defense of failure to state a
claim upon which relief can be granted may also be made by a
motion for judgment on the pleadings." Turbe v.
Gov't of Virgin Islands, 938 F.2d 426, 428 (3d Cir.
1991). Accordingly, when a Rule 12(c) motion asserts that the
complaint fails to state a claim, the familiar Rule 12(b)(6)
standard applies, making due allowance, of course, for any
factual allegations that are admitted in the responsive
pleading. Thus, 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).
general, review is confined to the allegations in the
pleadings. I am permitted, however, to consider
"extraneous documents that are referred to in the
complaint or documents on which the claims in the complaint
are based" without converting this motion into one for
summary judgment. Morano v. BMW of N. Am., LLC, 928
F.Supp.2d 826, 830 (D.N.J. 2013) (citing In re Burlington
Coat Factory Sec. Litig., 114 F.3d 1410, 1426 (3d Cir.
1997); Pension Benefit Guar. Corp. v. White Consol.
Indus., 998 F.2d 1192, 1996 (3d Cir. 1993)).
filed a letter (ECF no. 104) joining General Trading's
earlier-filed motion to dismiss the Amended Complaint.
Specifically, CHP cites General Trading's arguments that
the action was not timely filed and that plaintiff BMC lacks
standing because of an invalid assignment from its patient.
In my earlier Opinion (ECF no. 122) I denied General
Trading's motion. Specifically, I held that the Amended
Complaint adequately alleged a valid assignment (Op. 8-10)
and that it adequately alleged that the action was timely
under the terms of the plan. (Op. 10-12) For the reasons
expressed in my earlier Opinion, then, CHP's motion for
judgment on the pleadings (ECF no. 104) is denied, without
prejudice to renewal of these contentions in the context of