United States District Court, D. New Jersey
C. AGNER On behalf of Plaintiff
MICHAEL H. BERNSTEIN ROBINSON & COLE LLP CASSIE EHRENBERG
CLEARY, JOSEM & TRIGIANI LLP CONSTITUTION PLACE On behalf
L. HILLMAN, U.S.D.J.
a health care provider, has sued its patient's
ERISA-governed health benefits plan for unpaid medical bills.
Defendants have moved to dismiss Plaintiff's complaint,
arguing that Plaintiff has no viable claims because of an
anti-assignment of benefits clause in the patient's
health benefits plan. For the reasons expressed below,
Defendants' motion will be granted.
December 1, 2015 through May 31, 2016, Plaintiff, Enlightened
Solutions LLC, provided detoxification and rehabilitation
treatment to “JV” for his addiction. JV was
insured under his mother's health benefits plan, Unite
Here Health Plan Unit 102, which is governed by the Employee
Retirement Income Security Act of 1974 (as amended), 29
U.S.C. § 1001, et. seq. (“ERISA”), and
managed and administered by United Behavioral Health and
Optum Inc. (hereinafter collectively referred to as
“Defendants”). Plaintiff submitted claims to
Defendants pursuant to an Assignment of Benefits entered
between Plaintiff and JV, which stated, “I hereby
authorize and request that payment of benefits by my
Insurance Company(s), Optimum Blue Cross Blue Shield, be made
directly to Enlightened Solutions, LLC for services furnished
to me . . . .” (Docket No. 1-1 at 6-7.)
paid the claims for services provided on December 1, 2015
through January 29, 2016, and for services provided on March
10, 2016 through May 31, 2016. Defendants failed to pay
Plaintiff's claims for February 1, 2016 through March 10,
2016 in the amount of $27, 115. Plaintiff's complaint
seeks payment for the claims Defendants have not paid for
February and March 2016 based on Defendants' alleged
violations of ERISA, as well as its attorney's fees.
to Plaintiff's complaint, Defendants first denied those
claims because they did not meet the required medical
necessity. In response to Plaintiff's appeal, Defendants
again denied those claims, but this time on the grounds that
Plaintiff submitted its own Assignment of Benefits
(“AOB”) form rather than Defendants'
Assignment of Rights (“AOR”) form, and further
that the AOB was signed more than a year before the dates of
service. Plaintiff contends a denial on those bases
constituted an abuse of discretion and was arbitrary and
capricious because: (1) the AOB was not signed over a year
before the claims, (2) Plaintiff's AOB contained the same
information as Defendants' AOR, and (3) Defendants
previously accepted Plaintiff's AOB and paid those
has advanced two claims under ERISA. Plaintiff's first
count is failure to make all payments under 29 U.S.C. §
1132(a)(1)(B). Plaintiff's second count is for breach of
fiduciary duty and for equitable relief under 29 U.S.C.
§§ 1132(a)(3), 1104(a)(1), and 1105(a).
have moved to dismiss Plaintiff's claims because the
operative ERISA Plan contains a valid anti-assignment
provision which precludes Plaintiff's attempts to seek
reimbursement on behalf of its patient. Defendants also argue
that even though the Plan paid some of Plaintiff's claims
for services provided to its patient, the Plan explicitly
states that such payments do not constitute a waiver of the
anti-assignment provision. Defendants further argue that
Plaintiff lacks standing to pursue breach of fiduciary and
other similar claims because those are causes of action only
available to the patient himself. Plaintiff has opposed
Subject matter jurisdiction
removed this action to this Court from the Superior Court of
New Jersey, Law Division, Atlantic County pursuant to 28
U.S.C. §§ 1331, 1441(a) & (c), and 28 U.S.C.
§ 1446. Federal question jurisdiction exists in this
matter pursuant to 28 U.S.C. § 1331. ERISA further
provides that the district courts of the United States shall
have at least concurrent, and sometimes exclusive,
jurisdiction over the ERISA causes of action pleaded in the
complaint. 29 U.S.C. § 1132(e)(1).
Standard for Motion to Dismiss
Rule 12(b)(1) governs motions to dismiss for lack of
standing, as standing is a jurisdictional matter.”
N. Jersey Brain & Spine Ctr. v. Aetna, Inc., 801
F.3d 369, 371 n.3 (3d Cir. 2015). When, however, statutory
limitations to sue are non-jurisdictional, such as when a
party claims derivative standing to sue under ERISA §
502(a), a motion challenging such standing is “properly
filed under Rule 12(b)(6).” Id. (explaining
that in practical effect, a motion for lack of statutory
standing is effectively the same whether it comes under Rule
12(b)(1) or 12(b)(6)) (citation omitted).
considering a motion to dismiss a complaint for failure to
state a claim upon which relief can be granted pursuant to
Federal Rule of Civil Procedure 12(b)(6), a court must accept
all well-pleaded allegations in the complaint as true and
view them in the light most favorable to the plaintiff.
Evancho v. Fisher, 423 F.3d 347, 351 (3d Cir. 2005).
It is well settled that a pleading is sufficient if it