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Robinson v. Anthem Blue Cross Life and Health Insurance Co.

United States District Court, D. New Jersey

November 30, 2018



          Freda L. Wolfson United States District Judge

         In an Opinion issued on March 22, 2018, the Court dismissed Plaintiff Clifford Robinson's (“Plaintiff” or Mr. Robinson”) Complaint, asserting a claim under Section 502(a)(1)(B) of the Employee Retirement Income Security Act of 1974 (“ERISA”), arising from the partial denial of benefits under an employee health insurance benefits plan. Despite finding that Plaintiff failed to sufficiently plead facts demonstrating that Defendants Anthem Blue Cross Life and Health Insurance Company (“Anthem”) and Ashland LLC (“Ashland”) (cumulatively, “Defendants”) were obligated by the relevant ERISA Plan to pay for out-of-network services in accordance with the “usual and customary rate, ” the Court granted Plaintiff leave to amend. Subsequently, Plaintiff filed a First Amended Complaint against Defendants, amending his § 502(a)(1)(B) claim. Defendants now move to dismiss the First Amended Complaint, arguing that Plaintiff's amended § 502(a)(1)(B) claim, too, fails to sufficiently allege that Plaintiff is entitled to additional benefits. For the following reasons, Defendants' motion to dismiss is GRANTED. However, Plaintiff is given a final opportunity to amend his Complaint, consistent with the dictates of this Opinion, within twenty (20) days from the date of the Order accompanying this decision.


         The underlying facts of this dispute have been thoroughly set forth in the Court's previous March 22, 2018 Opinion and are incorporated herein. Atl. Plastic & Hand Surgery, PA v. Anthem Blue Cross Life & Health Ins. Co., No. 17-4699, 2018 U.S. Dist. LEXIS 4718 (D.N.J. March 22, 2018). Therefore, to avoid repetition, the Court will only provide a brief summary here.

         Michael S. Risin, M.D. (“Dr. Risin”), is a board certified plastic surgeon who is licensed to practice in the state of New Jersey. Am. Compl. ¶ 2. Dr. Risin is a shareholder in, or owner of, Atlantic Plastic & Hand Surgery PA (cumulatively with Dr. Risin, the “Providers”), [1] a healthcare provider with an office in Little Silver, New Jersey. Id. On February 12, 2014, Dr. Risin performed surgery and other medical services (the “Procedure”) on Mr. Robinson at the Riverview Medical Center in Red Bank, New Jersey. Id. ¶¶ 32, 37.

         Plaintiff is a member of, and participant in, a self-funded, ERISA governed employee health insurance benefits Plan (the “Plan”) that is sponsored by Ashland and administered by Anthem. Id. ¶¶ 6, 10-11. The Providers are “non-participating, ” “out-of-network providers” and the services provided to Plaintiff were “out-of network” services, as defined under the Plan, because the Providers did not contract with Anthem. Id. ¶¶ 33-34.

         Subsequent to the Procedure, the Providers submitted a claim to Anthem (the “Claim”), as the purported assignees of Plaintiff, requesting payment in the amount of $55, 761.30 for the out-of-network services that were provided to Plaintiff. Id. ¶ 38. On April 21, 2014, Anthem sent the Providers an explanation of benefits notice (the “EOB”), authorizing partial payment of the Claim to the Providers in the amount of $3, 501.60. Id. ¶ 40.

         On June 22, 2017, Plaintiff filed a two-count Complaint, seeking to recover the unpaid balance of the claim: (1) Count One asserted that Defendants violated § 502(a)(1)(B) of ERISA by, among other things, underpaying the Providers for the services rendered to Mr. Robinson, and (2) Count Two asserted that Plaintiff is entitled to attorneys fees and costs, pursuant to § 502(g)(1) of ERISA. Defendants subsequently filed a motion to dismiss, which this Court granted on March 22, 2018. However, Mr. Robinson was given leave to amend his claim under § 502(a)(1)(B) of ERISA. On April 20, 2018, Mr. Robinson filed his First Amended Complaint.

         In the instant matter, Defendants, once again, move to dismiss Plaintiff's First Amended Complaint for failure to state a claim, arguing that the additional facts pled therein fail to state a cognizable cause of action under § 502(a)(1)(B) of ERISA. Plaintiff opposes Defendants' motion to dismiss.


         A. Standard of Review

         Federal Rule of Civil Procedure 12(b)(6) provides that a court may dismiss a claim “for failure to state a claim upon which relief can be granted.” Fed.R.Civ.P. 12(b)(6). When reviewing a motion to dismiss, courts must first separate the factual and legal elements of the claims, and accept all of the well-pleaded facts as true. See Fowler v. UPMC Shadyside, 578 F.3d 203, 210-11 (3d Cir. 2009). All reasonable inferences must be made in the plaintiff's favor. See In re Ins. Brokerage Antitrust Litig., 618 F.3d 300, 314 (3d Cir. 2010). In order to survive a motion to dismiss, the plaintiff must provide “enough facts to state a claim to relief that is plausible on its face.” Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570 (2007). This standard requires the plaintiff to show “more than a sheer possibility that a defendant has acted unlawfully, ” but does not create as high of a standard as to be a “probability requirement.” Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009).

         The Third Circuit requires a three-step analysis to meet the plausibility standard mandated by Twombly and Iqbal. First, the court should “outline the elements a plaintiff must plead to a state a claim for relief.” Bistrian v. Levi, 696 F.3d 352, 365 (3d Cir. 2012). Next, the court should “peel away” legal conclusions that are not entitled to the assumption of truth. Id.; see also Iqbal, 556 U.S. at 678-79 (“While legal conclusions can provide the framework of a complaint, they must be supported by factual allegations.”). It is well-established that a proper complaint “requires more than labels and conclusions, and a formulaic recitation of the elements of a cause of action will not do.” Twombly, 550 U.S. at 555 (internal quotations and citations omitted). Finally, the court should assume the veracity of all well-pled factual allegations, and then “determine whether they plausibly give rise to an entitlement to relief.” Bistrian, 696 F.3d at 365 (quoting Iqbal, 556 U.S. at 679). A claim is facially plausible when there is sufficient factual content to draw a “reasonable inference that the defendant is liable for the misconduct alleged.” Iqbal, 556 U.S. at 678. The third step of the analysis is “a context-specific task that requires the reviewing court to draw on its judicial experience and common sense.” Id. at 679.

         B. ...

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