CAPE REGIONAL MEDICAL CENTER v. CIGNA HEALTH AND LIFE INSURANCE COMPANY, No. 1:2017cv05284 - Document 32 (D.N.J. 2018)
Court Description: OPINION. Signed by Judge Joseph H. Rodriguez on 6/14/2018. (dmr)
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CAPE REGIONAL MEDICAL CENTER v. CIGNA HEALTH AND LIFE INSURANCE COMPANY Doc. 32 UNITED STATES DISTRICT COURT DISTRICT OF NEW J ERSEY CAPE REGIONAL MEDICAL CENTER : on assignments of 52 individual patients, Plaintiffs, : v. : CIGNA HEALTH AND LIFE INS. CO., Defendant. Hon. J oseph H. Rodriguez Civil Action No. 17-5284 OPINION : : This m atter has com e before the Court on Defendant’s Motion to Dism iss the Com plaint pursuant to Federal Rule of Civil Procedure 12(b)(6) for failure to state a claim . The Court has considered the subm issions of the parties and decides this m otion on the papers pursuant to Federal Rule of Civil Procedure 78(b). For the reasons stated here, Defendant’s m otion [Doc. 12] will be granted. Background Plaintiff Cape Regional Medical Center, as assignee, seeks reim bursement of approxim ately $ 357,416.47 of allegedly underpaid benefits from Defendant Cigna Health and Life Insurance Com pany for em ergency m edical services provided to 52 individual patients who were beneficiaries of Defendant’s health benefits plan governed by ERISA. 1 1 Plaintiff has stipulated to dism issal with prejudice of Counts Two (Breach 1 Dockets.Justia.com Motion to Dism iss Standard Federal Rule of Civil Procedure 12(b)(6) perm its a m otion to dism iss “for failure to state a claim upon which relief can be granted[.]” For a com plaint to survive dism issal under Rule 12(b)(6), it m ust contain sufficient factual m atter to state a claim that is plausible on its face. Ashcroft v. Iqbal, 556 U.S. 662, 678 (20 0 9) (quoting Bell Atl. Corp. v. Twom bly, 550 U.S. 544, 570 (20 0 7)). A claim is facially plausible “when the plaintiff pleads factual content that allows the court to draw the reasonable inference that the defendant is liable for the m isconduct alleged.” Id. Further, a plaintiff m ust “allege sufficient facts to raise a reasonable expectation that discovery will uncover proof of her claim s.” Connelly v. Lane Const. Corp., 80 9 F.3d 780 , 789 (3d Cir. 20 16). In evaluating the sufficiency of a complaint, district courts m ust separate the factual and legal elem ents. Fowler v. UFMC Shadyside, 578 F.3d 20 3, 210 -11 (3d Cir. 20 0 9) (“Iqbal ... provides the final nail-in-the-coffin for the ‘no set of facts’ standard that applied to federal com plaints before Twombly.”). The Court “m ust accept all of the com plaint’s well-pleaded facts as true,” Fowler, 578 of Contract) and Four (Breach of Fiduciary Duty). As such, the claim s at issue in this m otion are Counts One (Failure to Com ply with Em ergency Service Cost Sharing Requirem ent of N.J .A.C. 11:4-37) and Three (Failure to Make All Paym ents Pursuant to Mem ber’s Plan under 29 U.S.C. §1132(a)(1)(B)). 2 F.3d at 210 , “and then determ ine whether they plausibly give rise to an entitlem ent for relief.” Connelly, 80 9 F.3d at 787 (citations om itted). Restatem ents of the elements of a claim , however, are legal conclusions and, therefore, not entitled to a presum ption of truth. Burtch v. Milberg Factors, Inc., 662 F.3d 212, 224 (3d Cir. 20 11). Discussion Count One, alleging a violation under N.J . Adm in. Code § 11:4-37, is preem pted by ERISA because it is a claim for benefits allegedly due under section 50 2(a)(1)(B) of the federal statute. Congress enacted ERISA to create “a uniform regulatory regim e over employee benefit plans.” Aetna Health Inc. v. Davila, 542 U.S. 20 0 , 20 8 (20 0 4); see New J ersey Carpenters & the Trustees Thereof v. Tishm an Const. Corp. of New J ersey, 760 F.3d 297, 30 3 (3d Cir. 20 14) (“Congress enacted ERISA to ensure that benefit plan adm inistration was subject to a single set of regulations and to avoid subjecting regulated entities to conflicting sources of substantive law.”). To determ ine whether a state law claim is com pletely preempted under Section 50 2(a), a court m ust determ ine that (1) the plaintiff could have brought the action under Section 50 2(a) of ERISA and (2) no independent legal duty supports the plaintiff’s claim. Pascack Valley Hosp. v. Local 464A UFCW Welfare Reimbursem ent Plan, 388 F.3d 393, 40 0 (3d Cir. 20 0 4); see 3 also Davila, 542 U.S. at 210 (holding that state law claim is com pletely preem pted when action could have been brought under Section 50 2(a)(1)(B) and no other legal duty independent of ERISA exists). A claim m ay be brought under Section 50 2(a) of ERISA by a participant or beneficiary “to recover benefits due to him under the term s of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan.” 29 U.S.C. 1132(a); see also Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 53 (1987). In determ ining whether a plaintiff’s state law claim s “are predicated on a legal duty that is independent of ERISA,” Pascack Valley, 388 F.3d at 393, a court “m ust exam ine whether interpretation or application of the term s and scope of the ERISA insurance plan form an ‘essential part’ of Plaintiff’s claim s.” North J ersey Brain & Spine Ctr. v. Conn. Gen. Life Ins. Co., No. 10 4260 , 20 11 WL 47370 67, at *6 (D.N.J . J une 30 , 20 11). Thus, this prong often turns on whether a plaintiff's claim s are “inextricably intertwined with the interpretation and application of ERISA plan coverage and benefits.” Id. at *7. In this case, Plaintiff claim s that it received valid assignments and has brought ERISA claim s pursuant to the assignments. Therefore, Plaintiff’s claim could be brought pursuant to Section 50 2(a). Indeed, whether 4 Plaintiff has a right to recover depends entirely on interpretation of term s and provisions of the ERISA plan. There is no independent basis for Plaintiff’s claim for benefits. “[C]ourts routinely preempt state com m on law claim s like the one[] raised here that involve denial of benefits under an ERISA-governed plan.” Advanced Orthopedics & Sports Medicine Institute v. Em pire Blue Cross Blue Shield, Civ. No. 17-8697, 20 18 WL 2758221, *7 (D.N.J . J une 7, 20 18). See also Cohen v. Horizon Blue Cross Blue Shield of New J ersey, Civ. No. 15-4525, 20 17 WL 68510 1, *6-7 (D.N.J . Feb. 21, 20 17) (finding claim of violation of New J ersey em ergency services regulation at N.J . Adm in. Code § 11:24-5.3 com pletely preem pted). Accordingly, Count One is preem pted by ERISA and m ust be dism issed. Even if Count One was not preempted by ERISA, it still m ust be dism issed because N.J . Adm in. Code. § 11:4-37.3 does not provide a private right of action. See R.J . Gaydos Ins. Agency, Inc. v. Nat’l Consum er Ins. Co., 773 A.2d 1132, 1144 (N.J . 20 0 1) (“New J ersey courts have generally declined to infer a private right of action in statutes where the statutory schem e contains civil penalty provisions.”). To determ ine if a statute confers an implied private right of action, courts consider whether: (1) plaintiff is a m em ber of the class for whose special benefit the statute was enacted; (2) there is any evidence that the Legislature intended to create a private right of action under the statute; and (3) it is consistent with the 5 underlying purpose of the legislative scheme to infer the existence of such a remedy. Id. at 1143. “The Court considers the sam e factors to determ ine if an adm inistrative regulation confers an im plied private right of action.” N.J . Thoroughbred Horsemen’s Ass’n v. Alpen House U.L.C., 942 F. Supp. 2d 497, 50 4 (D.N.J . 20 13) (citing J alowiecki v. Leuc, 440 A.2d 21, 25-26 (N.J . Super. Ct. App. Div. 1981)). There is no indication that the New J ersey Legislature intended to create a private right of action under § 11:437.3. See N.J . Thoroughbred Horsem en’s, 942 F. Supp. 2d at 50 4-0 5; R.J . Gaydos Ins. Agency, Inc., 773 A.2d at 1148 (“refusing to recognize implied private cause of action against insurance com pany in light of com prehensive regulation of insurance industry”). Rather, New J ersey’s Com m issioner of Insurance possesses the exclusive power to enforce the regulation and im pose penalties in the case of violations. Therefore, Count One will be dism issed. Next, Count Three seeking ERISA plan benefits will be dism issed because it fails to satisfy fundamental pleading requirements. Specifically, the Com plaint does not identify facts such as the dates upon which services were rendered for each patient, the nature of the services provided to each patient, the am ounts charged to each patient, the term s of the assignments 6 of benefits, the specific plans or policies that are controlling, or the provisions of plans that Defendant allegedly violated. The bald allegation that Plaintiff, as an out-of-network provider, was not paid the entirety of what it was owed is insufficient to survive a m otion to dism iss. See Re: Com plete Foot & Ankle v. CIGNA Health & Life Ins. Co., Civ. No. 17-13742, 20 18 WL 2234653, *2 (D.N.J . May 16, 20 18) (under same facts, finding Com plaint that contained little m ore than an assertion that plaintiff was owed m ore than it was paid for the services it provided insufficient under Fed. R. Civ. P. 8 and dism issing plaintiff’s argum ent that m otion to dism iss should be denied because defendant failed to produce the relevant plan docum ents because “Plaintiff, as an alleged assignee, steps into the beneficiaries’ shoes, who at all tim es had access to the Plans.”); LeMoine v. Em pire Blue Cross Blue Shield, Civ. No. 16-6786, 20 18 WL 1773498, at *6 (D.N.J . Apr. 12, 20 18) (granting m otion to dism iss, finding plaintiff “fail[ed] to plausibly plead which portions of [benefit plans] have been violated); Atlantic Plastic & Hand Surgery, PA v. Anthem Blue Cross Life & Health Ins. Co., Civ. No. 17-460 0 , 20 18 WL 1420 496, at *10 -11 (D.N.J . Mar. 22, 20 18) (dism issing claim where plaintiff’s “threadbare allegations” did not point “to any provision of a . . . benefit plan suggesting” an entitlem ent to payment). 7 Plaintiff’s failure to identify the specific plans or policies that are controlling is also problematic in that Defendant cannot determ ine whether its relevant policies contained anti-assignm ent clauses. See Am erican Orthopedic & Sports Medicine v. Independence Blue Cross Blue Shield, 890 F.3d 445 (3d Cir. 20 18) (holding that anti-assignment clauses in ERISAgoverned health insurance plans are enforceable). In short, Plaintiff has not pled a sufficient factual basis that would allow the Court to infer that the Defendant is liable for a plausible claim of wrongful denial of benefits under section 50 2(a)(1)(B) of ERISA, which requires a plaintiff to dem onstrate entitlem ent to “benefits due to him under the term s of his plan.” 29 U.S.C. § 1132(a)(1)(B) (emphasis added). Accordingly, Count Three will be dism issed. Conclusion For these reasons, Defendant’s Motion to Dism iss the Com plaint will be granted. An Order will accom pany this Opinion. Dated: J une 14, 20 18 / s/ J oseph H. Rodriguez J OSEPH H. RODRIGUEZ U.S.D.J . 8
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