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Enlightened Solutions, LLC v. United Behavioral Health

United States District Court, D. New Jersey

December 4, 2018


          JOHN C. AGNER On behalf of Plaintiff



          NOEL L. HILLMAN, U.S.D.J.

         Plaintiff, 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.


         From 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.)

         Defendants 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.

         According 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 claims.

         Plaintiff 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).

         Defendants 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 Defendants' motion.


         A. Subject matter jurisdiction

         Defendants 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).

         B. Standard for Motion to Dismiss

         “Ordinarily, 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).

         When 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 contains ...

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