United States District Court, D. New Jersey
L. Wolfson United States District Judge
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
“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.
FACTUAL BACKGROUND AND PROCEDURAL HISTORY
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.
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”),  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.
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. ¶¶
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.
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
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.
Standard of Review
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).
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.