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Small v. Oxford Health Insurance, Inc.

United States District Court, D. New Jersey

February 19, 2019

TZVI SMALL, M.D., Plaintiff,
v.
OXFORD HEALTH INSURANCE, INC., et al., Defendants.

          OPINION

          J0SE L. LINARES CHIEF JUDGE

         This matter comes before the Court by way of Defendants Oxford Health Insurance, Inc. and United Healthcare Services, Inc.'s Motion to Dismiss Plaintiff Tzvi Small, M.D.'s Complaint, pursuant to Federal Rule of Civil Procedure 12(b)(6). (ECF No. 8). Plaintiff submitted opposition. (ECF No. 11). Despite being granted additional time by this Court, (ECF No. 15), Defendants did not file a reply. The Court has considered the parties' submissions and decides this matter without oral argument pursuant to Federal Rule of Civil Procedure 78. For the reasons stated herein, the Court hereby denies Defendants' Motion in part, with the exception that the Court shall dismiss Plaintiffs claim for quantum meruit.

         I. BACKGROUND[1]

         Patient "D.H." is insured by and receives medical benefits from Defendants, which are insurance companies with their principal places of business in Connecticut. (Compl. ¶¶ 2-3, 7; ECF No. 1 ¶ 7). Plaintiff is a plastic surgeon who practices in New Jersey. (Compl. ¶¶ 1, 6, 18). Plaintiff is not a participating provider in Defendants' insurance network. (Compl. ¶ 14). Plaintiff alleges that he received written authorization from Defendants to perform a "medically-necessary" breast reconstruction surgery on Patient. (Compl. ¶¶ 16 17). Plaintiff performed said surgery on December 19, 2016. (Compl. ¶ 17).

         After the surgery, Plaintiff requested payment from Defendants in the amount of $ 129, 600, which according to Plaintiff "represents [the] normal and reasonable charges for the complex procedure performed by a Board-Certified Plastic Surgeon and Surgeon practicing in New Jersey." (Compl. ¶ 19). However, Plaintiff claims that Defendants only paid around $10, 639, which left a remaining balance of $118, 960.75. (Compl. ¶ 20). Plaintiff alleges that Defendants: (1) were aware that Plaintiff was not a provider in their network; (2) did not disclose to Plaintiff that they would not pay the full amount of the surgery; and (3) induced Plaintiff to perform the surgery with no intention of paying the full amount. (Compl. ¶ 21).

         In addition to the above allegations, Plaintiff also alleges that Medical Audit and Review Solutions ("Review Solutions") contacted him at some point after the surgery. (Compl. ¶ 23).

         According to Plaintiff, Review Solutions was an agent of Defendants and attempted to resolve Plaintiffs claim against Defendants for the cost of the surgery. (Compl. ¶ 23). Plaintiff alleges that Review Solutions offered Plaintiff S31, 055.20 if Plaintiff forgave the remaining balance of the surgery. (Compl. ¶ 23). Plaintiff accepted this agreement, which was allegedly memorialized in writing ("the Agreement"). (Compl. ¶¶ 23 -24). Specifically, the Agreement was dated January 9, 2017 and stated:

Pursuant to our recent conversation, by signing below, [Plaintiff] agrees to: (i) accept the Agreed Amount [of $31, 055.20] (less deductible, co-insurance, co-payment or other patient responsibility or non-covered services as defined by the plan) as payment in full for claims/bills from plans serviced by MultiPlan that are submitted by [Defendants] and determined to be eligible for the services rendered to the Patient on the dates listed above; (ii) not to balance bill the Patient for the difference between the Amount of the Claim/Bill and the Agreed Amount; and (iii) reduce the liability of the Patient and [Defendants].
By signing below, the Provider agrees and acknowledges that: (i) [Review Solutions] and MultiPlan are not payors and are not financially responsible for any payments due to [Plaintiff]; (ii) the payment of benefits, if any, is subject to the terms and conditions of the Patient's plan; and (iii) this agreement does not constitute, nor should it be construed as a guarantee of benefit payment by [Defendants]. [Plaintiff] retains the right to bill the Patient (or financially responsible party) for items not covered under the Patient's benefit plan.

(ECF No. 11-10 at 2 ("Agreement")).

         Despite the Agreement, Plaintiff claims that Defendants never made any payment beyond the original amount of approximately $10, 639. (Compl. ¶ 26). Plaintiff argues that Defendants' failure to pay the remaining $20, 415.92 was a breach of the Agreement. (Compl. ¶ 27). Furthermore, Plaintiff claims in the alternative that the course of conduct between the parties, and particularly Defendants' authorization of the surgery, created an implied contract in which Defendants agreed to pay "the fair and reasonable rates for" performing the surgery, i.e., the remaining balance of $118, 960.75. (Compl. ¶¶ 29-33).

         Accordingly, Plaintiff brought suit in New Jersey Superior Court, alleging the following causes of action: (1) Breach of the Agreement ("Count One"); (2) Breach of Implied Contract ("Count Two"); (3) Promissory Estoppel ("Count Three"); (4) Account Stated ("Count Four"); and (5) Quantum Meruit ("Count Five"). (Compl. ¶¶ 22-51). Defendants removed the action to this Court. (ECF No. 1). Now, Defendants move to dismiss Plaintiff s Complaint.

         II. LEGAL STANDARD

         To withstand a motion to dismiss for failure to state a claim, 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)). "A claim has facial plausibility when the plaintiff pleads factual content that allows the court to draw the reasonable inference that the defendant is liable for the misconduct alleged." Id. (citing Twombly, 550 U.S. at 556). "The plausibility standard is not akin to a 'probability requirement,' but it asks for more than a sheer possibility that a defendant has acted unlawfully." Id. (quoting Twombly, 550 U.S. at 556).

         To determine the sufficiency of a complaint under Twombly and Iqbal in the Third Circuit, the Court must: (1) "tak[e] note of the elements [the] plaintiff must plead to state a claim"; (2) "identify allegations that, because they are no more than conclusions, are not entitled to the assumption of truth"; and (3) "[w]hen there are well-pleaded factual allegations, [the] court should assume their veracity and then determine whether they plausibly give rise to an entitlement to relief." Connelly v. Lane Constr. Corp., 809 F.3d 780, 787 (3d Cir. 2016) (internal quotations and citations omitted). "In deciding a Rule 12(b)(6) motion, a court must consider only the complaint, exhibits attached to the complaint, matters of public record, as well as undisputedly authentic documents if the complainant's claims are based upon these documents." Mayer v. Belichick, 605 F.3d 223, 230 (3d Cir. 2010).

         III. ...


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