Bloom v. Independence Blue Cross

152 F. Supp. 3d 431, 60 Employee Benefits Cas. (BNA) 2332, 2015 WL 4598016, 2015 U.S. Dist. LEXIS 100106
CourtDistrict Court, E.D. Pennsylvania
DecidedJuly 31, 2015
DocketCivil Action No. 14-2582
StatusPublished
Cited by3 cases

This text of 152 F. Supp. 3d 431 (Bloom v. Independence Blue Cross) is published on Counsel Stack Legal Research, covering District Court, E.D. Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Bloom v. Independence Blue Cross, 152 F. Supp. 3d 431, 60 Employee Benefits Cas. (BNA) 2332, 2015 WL 4598016, 2015 U.S. Dist. LEXIS 100106 (E.D. Pa. 2015).

Opinion

[433]*433MEMORANDUM

McHUGH, District Judge.

This case involves the broad but sometimes hard to define scope of jurisdiction under the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq. (“ERISA”). The central question: is this case a simple payment dispute, unworthy of federal jurisdiction, or are Plaintiffs, even though they are providers, properly raising an issue as to the scope of patients’ coverage, giving rise to interests protected by ERISA?

Plaintiffs are Dr. Howard Bloom, a chiropractor, and his practice, Weather Vane Chiropractic, P.C. Defendants are insurance providers, Independence Blue Cross, Inc. (“IBC”), QCC Insurance Company, Keystone Health Plan East, Inc., and Am-eriHealth HMO, Inc. From May 2005 until October 2013, Dr. Bloom was a participating- provider in Defendants’ network of health care providers. Together, Defendants and Dr. Bloom, as an in-network provider, offered medical services to plan beneficiaries under the terms of their health care plans (“IBC Plans”). During the course of his business relationship with Defendants, Dr. Bloom’s individual rights and duties as an in-network provider were separately governed by a Professional Provider Agreement (“Provider Agreement”).

Plaintiffs assert that IBC rescinded coverage for certain medical procedures, after allegedly covering those same, services for years, and have brought suit to enforce what they contend are their individual and derivative rights under the relevant IBC plans governed by ERISA. Specifically, Plaintiffs allege that Defendants’ retroactive denial of covered benefits amounted to an “Adverse Benefits Determination” under ERISA, triggering the notice and appeal process afforded to plan beneficiaries by the statute. In addition, Plaintiffs directly bring supplemental state law claims, including breach of the Provider Agreement, fraud, negligent misrepresentation, and malicious prosecution. Defendants have moved to dismiss ' the entirety of Plaintiffs’ First Amended Complaint, arguing Plaintiffs fail to state plausible ERISA claims, depriving this Court of subject matter jurisdiction. Because I am persuaded that Plaintiffs allege an ERISA coverage dispute under the IBC Plans via a valid assignment of rights from the plan participants, as opposed to a simple payment dispute under the Provider' Agreement, Defendants’ Motion to Dismiss will be denied.

I. Relevant Facts Alleged in Plaintiffs’ First Amended Complaint

Plaintiffs’ First Amended Complaint includes various details of the dispute that are not essential to resolving the instant Motion to Dismiss. In the description- of the facts below, I focus only on those allegations that are particularly relevant to the current Motion.

Dr. Howard Bloom is a licensed chiropractor in Pennsylvania who conducts his professional practice through Plaintiff Weather Vane Chiropractic,, P.C. (‘Weather Vane”). First Amended Complaint ¶ 15. Including its subsidiaries, Plaintiff identifies Defendant IBC as the leading health insurer in southeastern Pennsylvania, , administering health. insurance benefits of more than 2.2 million Pennsylvanians. Id, at ¶ 21.

“Pursuant to the terms of the applicable IBC Plans, IBC is required to provide IBC Plan Beneficiaries-with payment or reimbursement for- specified covered, health care services (‘Covered Services’).” Id. at ¶ 22. “IBC Plan Beneficiaries” include direct plan participants, as well as their eligible spouses and children. Id. at ¶ 5. In order to receive the full extent of benefits under the IBC- Plans, beneficiaries are often required to obtain Covered Services by [434]*434utilizing “in-network” or “participating providers,”' since those providers have contractually agreed to participate in the applicable IBC plan and to render care on a fixed fee basis, as separately regulated by individual “provider agreements.” Id. .at ¶22. Stated differently, the IBC Plans control what services are considered “Covered Services” for beneficiaries, while provider agreements dictate the rights and responsibilities of the provider in performing those services. Of greatest significance here, the Provider Agreement at issue, which sets fees, does not in any way purport to control what medical services are eligible, for coverage under the relevant IBC plans..

In May 2005, Dr. Bloom signed a Professional Provider Agreement with Defendants QCC, Keystone, and AmeriHealth (together, “Independence”). Id. at ¶37. The purpose of the Agreement is readily apparent on the first page: “Independence and [Dr. Bloom] mutually desire to enter into this Agreement whereby [Dr. Bloom] shall render Covered Services to Beneficiaries of the various Benefit Programs and ' shall be compensated by Independence therefor, as more explicitly described hereafter.” Memorandum of Law In ■ Support of Defendants’ Motion to Dismiss, Exhibit A at 1. “Covered Services” are defined in the Provider Agreement as “Medically Necessary health care services and supplies that are to be provided by [Dr. Bloom] to Beneficiaries for which a Beneficiary has coverage pursuant to the applicable Benefit...Program or Benefit Program Agreement.” Id. at ¶ 1.10.

Patients at Dr. Bloom’s practice, Weather Vane, ordinarily signed a standard “Financial Policy” form, which included the following assignment clause: “THIS- IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY.” . First Amended Complaint at ¶ 122. Weather Vane’s services included massage therapy provided by licensed massage therapists, known as “Delegated Adjunctive Therapeutic Massage Procedures” (“DATMP”). Id. Weather Vane provided DATMP to patients “for more than five years prior to 2006.” Id. at ¶47. During the pre-2006 time period, Defendants considered DATMP to qualify as a Covered Service under the relevant IBC plans and paid Dr. Bloom directly for those procedures. Id.

In 2006, IBC issued a billing guide supplement that informed participating providers that IBC would cover massage, but would not cover any services performed by a massage therapist. Id. at ¶¶ 49-51. The guide provided: “Note: IBC. does not provide reimbursement for services that are performed by a massage therapist. This applies to independently practicing massage therapists as well as those who are employed and supervised by an eligible health care professional.” Id. at ¶ 51. .

Dr. Bloom alleges the note- “was not incorporated or referenced in the Provider Agreement or, on information and belief, in the plan documents of IBC Plan Beneficiaries.” Id. at ¶53. Accordingly, Dr. Bloom submits that the billing note did not, and could not, preclude reimbursement for DATMP; Id. at ¶ 54. Moreover, Dr. Bloom alleges that despite the billing note, IBC continued to pay for DATMP services provided to beneficiaries who were covered for such procedures undér their applicable IBC plans. Id. at ¶ 55.

However, IBC . reversed course in 2007 and demanded reimbursement for “over-payments” made to Dr. Bloom and other Pennsylvania chiropractors by Keystone for massage services provided to their insureds from ,2006 to 2007, claiming those massage procedures were- not Covered Services under the applicable Keystone plans. Id. at ¶ 56. After receiving push-back regarding the legality of the over[435]

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Related

Anand v. Independence Blue Cross
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MAYER v. AETNA INC.
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Howard Bloom, D.C. & Weather Vane Chiropractic, P.C. v. Cross
340 F. Supp. 3d 516 (E.D. Pennsylvania, 2018)

Cite This Page — Counsel Stack

Bluebook (online)
152 F. Supp. 3d 431, 60 Employee Benefits Cas. (BNA) 2332, 2015 WL 4598016, 2015 U.S. Dist. LEXIS 100106, Counsel Stack Legal Research, https://law.counselstack.com/opinion/bloom-v-independence-blue-cross-paed-2015.