United States District Court, D. New Jersey
MEMORANDUM AND ORDER
G. SHERIDAN, U.S.D.J.
matter comes before the Court on defendants" motion to
dismiss plaintiffs amended complaint, (ECF No. 12). This case
arises from a dispute over nonpayment of medical services.
Plaintiff New Jersey Neck and Back Institute is a company
that provides healthcare services. (Amended Compl. at ¶
1; ECF No. 1). On July 8, 2014, Sandro LaRocca M.D., employed
by plaintiff, performed surgery on nonparty R.V.
(Id. at ¶¶ 15). The surgery included an
anterior disketomy, anterior arthrodesis, and a placement of
a PEEK Interbody spacer. (Id. at ¶ 15).
received health coverage through Highmark Blue Cross Blue
Shield (hereinafter "HBCBS"), sponsored by
Connoisseur Media, LLC. (Id. at ¶ 5; see
also Def. Ex. B, ECF No. 12- 4). The plan is an employee
welfare benefit plan, as defined by ERISA. (See Def.
Br. at 3). The plan contains the following provision:
The right of a Member to receive payment is not assignable,
except to the extent required by law, nor may benefits of
this Contract be transferred either before or after Covered
Services are rendered.
[(Def. Ex. B, ECF No. 12-4, at 96)].
plaintiff was an out of network or non-participating medical
provider, it contacted HBCBS to receive an authorization to
render medical services to R.V. (Amended Compl., ECF No. 11,
at ¶ 14). On June 19, 2014, plaintiff received from
HBCBS an authorization under authorization number 6787146.
(Id; see also Def. Ex. C, ECF No. 12-5). The
authorization letter explained that while the "inpatient
admission has been approved, the authorization is solely for
the purpose of advising you of the medical necessity of the
requested service. It is NOT a verification of available
benefits or authorization for new benefits. No. guarantee of
payment is being made[.]" (Def. Ex. C, ECF No. 12-5, at
Plaintiff then performed the surgery on R.V. (Amended Compl.,
ECF No. 11, at ¶¶ 15-16). After completion of the
surgery, plaintiff billed HBCBS $90, 125.00. (Id. at
¶ 18). HBCBS paid only $3, 266.72 toward the charges,
leaving a balance of $86, 858.28. (Id. at¶2O).
Plaintiff filed an amended complaint on June 27, 2018,
bringing a breach of implied contract claim (Count I), a
promissory estoppel claim (Count II), an account stated claim
(Count III), a fraudulent inducement claim (Count IV), a
claim for failure to make all payments pursuant to a members
plan under 29 U.S.C. 1132 § (a)(1)(B) (Count V), a claim
for breach of fiduciary duty under 29 U.S.C. §
1132(a)(3) and 29 U.S.C. § 1104(a)(1) (Count VI), and a
claim for failure to establish/maintain reasonable claims
procedures under 29 C.F.R. 2560.503.1 (Count VII).
before the Court is HBCBS's motion to dismiss. (ECF No.
12). HBCBS argues that plaintiffs claims must be dismissed
because: (1) plaintiffs state law claims are preempted by
ERISA; (2) plaintiffs state law claims fail to state a claim
against HBCBS under New Jersey Law; and (3) plaintiffs ERISA
claims must be dismissed because plaintiff lacks standing to
bring these claims. In response, plaintiff argues that its
claims are not preempted by ERISA, and it has sufficiently
pleaded state law causes of action against HBCBS.
standard On a motion to dismiss for failure to state a claim
pursuant to Fed.R.Civ.P. 12(b)(6), the Court is required to
accept as true all allegations in the complaint and all
reasonable inferences that can be drawn therefrom, and to
view them in the light most favorable to the non-moving
party. See Oshiver v. Levin, Fishbein, Sedran &
Berman, 38 F.3d 1380, 1384 (3d Cir. 1994). "To
survive a motion to dismiss, a complaint must contain
sufficient factual matter, accepted as true, to "state a
claim to relief that is plausible on its face.'"
Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009) (quoting
Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570
(2007)). The Third Circuit set forth a three-part analysis
for determining whether not a complaint may survive a motion
to dismiss for failure to state a claim:
First, the court must "tak[e] note of the elements a
plaintiff must plead to state a claim.,, Second,
the court should identify allegations that, "because
they are no more than conclusions, are not entitled to the
assumption of truth." Finally, "where there are
well-pleaded factual allegations, a court should assume their
veracity and then determine whether they plausibly give rise
to an entitlement for relief."
Santiago v. Warminster Twp., 629 F.3d 121, 130 (3d
Cir. 2010, ); see also Bistrian v. Levi, 696 F.3d
352, 365 (3d Cir. 2012).
last step is 'a context-specific task that requires the
reviewing court to draw on its judicial experience and common
sense.'" Bistrian, 696 at 365 (quoting
Iqbal, 556 U.S. at 679).
court will accept well-pleaded allegations as true for the
purposes of the motion, it will not accept bald assertions,
unsupported conclusions, unwarranted inferences, or sweeping
legal conclusions cast in the form of factual allegations.
Iqbal, 556 U.S. at 678-79; see also Morse v.
Lower Merion School District, 132 F.3d 902, 906 (3d Cir.
1997). A complaint should be dismissed only if the
well-pleaded alleged facts, taken as true, fail to state a
claim. See In re Warfarin Sodium, 214 F.3d 395,
397-98 (3d Cir. 2000). The question is whether the claimant
can prove any set of facts consistent with his or her
allegations that will entitle him or her to relief, not
whether that person will ultimately prevail. Semerenko v.
Cendant Corp., 223 F.3d 165, 173 (3d Cir.), cert.
denied, Forbes v. Semerenko, 531 U.S. 1149 (2001).
possesses 'extraordinary pre-emptive power.*"
Menkes v. Prudential Ins. Co. of Am.,762 F.3d 285,
293 (3d Cir. 2014) (quoting Metro. Life Ins. Co. v.
Taylor,481 U.S. 58, 65 (1987)). ERISA provides for two
types of preemption. Under ERISA's civil enforcement
provision, Section 502(a), "state law causes of action
that are within the scope of... § 502(a) are completely
pre-empted." Pascack Valley Hosp., Inc. v. Local
464A UFCW Welfare Reimbursement Plan,388 F.3d 393, 400
(3d Cir. 2004) (quotation omitted). Additionally, section
514(a) states that ERISA "shall supersede any and all
State laws insofar as they may now or hereafter relate to any
employee benefit plan" as defined under the Act. 29
U.S.C. § 1144(a). "Complete preemption under §
502(a) is a 'jurisdictional concept,' whereas express
preemption under § 514 is a 'substantive concept
governing the applicable law.'" Bauman v. In re
U.S. Healthcare, Inc. (In re U.S. Healthcare, Inc.), 193
F.3d 151, 160 (3d Cir. 1999) (quoting N.J. Carpenters v.
Tishman Constr. Corp.,760 F.3d 297, 302 (3d Cir.
2014)). "Unlike ordinary preemption, which would only
arise as a federal defense to a state-law claim, complete
preemption operates to confer original federal subject matter
jurisdiction notwithstanding the absence of a federal cause
of action on the face of the complaint. The Supreme Court has
held that "in enacting the civil-enforcement provisions
of section 502(a) of ERISA, Congress intended to completely
preempt state law." Id. In In re U.S.