BRAINBUILDERS LLC v. EMBLEMHEALTH, INC.

CourtDistrict Court, D. New Jersey
DecidedMay 21, 2021
Docket3:20-cv-12703
StatusUnknown

This text of BRAINBUILDERS LLC v. EMBLEMHEALTH, INC. (BRAINBUILDERS LLC v. EMBLEMHEALTH, INC.) is published on Counsel Stack Legal Research, covering District Court, D. New Jersey primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
BRAINBUILDERS LLC v. EMBLEMHEALTH, INC., (D.N.J. 2021).

Opinion

UNITED STATES DISTRICT COURT DISTRICT OF NEW JERSEY

___________________________________ BRAINBUILDERS LLC, and H and D, by : Civil Action No. 20-12703 (FLW)(TJB) their Attorney-in-Fact, ROCHEL : SOROTZKIN, : : OPINION Plaintiffs, : : v. : : EMBLEMHEALTH, INC., GROUP : HEALTH INCORPORATED, THE CITY : OF NEW YORK, NEW YORK CITY : OFFICE OF LABOR RELATIONS, and : NEW YORK CITY DEPARTMENT OF : EDUCATION, : Defendants. : ___________________________________ :

WOLFSON, United States Chief District Judge: Plaintiff Brainbuilders LLC (“Plaintiff”), a therapeutic intervention agency that provides services to children with autism spectrum disorders, initiated the instant action against defendants EmblemHealth, Inc., Group Health Incorporated (collectively, “GHI”), the City of New York, the New York City Office of Labor Relations (“OLR”), and the New York City Department of Education (“DOE”) (the “New York Defendants”) (New York Defendants together with GHI, “Defendants”), to recover payment for services rendered to a minor child pursuant to a GHI health plan. GHI and the New York Defendants filed separate motions to dismiss Plaintiff’s Complaint pursuant to Federal Rules of Civil Procedure 12(b)(2) and 12(b)(6), or, in the alternative, to transfer the case to the United States District Court for the Southern District of New York. For the following reasons, this Court lacks personal jurisdiction over the New York Defendants and this matter is transferred to the United States District Court for the Southern District of New York, in lieu of dismissal, pursuant to 28 U.S.C. §1631 and §1404(a). I. FACTUAL BACKGROUND AND PROCEDURAL HISTORY In addressing Defendants’ Motions to Dismiss, this Court must accept the allegations from Plaintiff’s Complaint as true. See Toys “R” Us, Inc. v. Step Two, S.A., 318 F.3d 446, 457 (3d Cir. 2003); Dayhoff, Inc. v. H.J. Heinz Co., 86 F.3d 1287, 1302 (3d Cir. 1996). Thus, the facts recited

below are taken from Plaintiff’s Amended Complaint (“Am. Compl.”) and do not represent this Court’s factual findings. Brainbuilders is located in New Jersey and it provides therapeutic services such as applied behavioral analysis (“ABA”), physical therapy, occupational therapy, and speech therapy, to children with autism spectrum related disorders (“ASDs”). ECF No. 14, Am. Compl. ¶1. ABA is purportedly “the single most effective and widely practiced treatment for individuals diagnosed with an ASD.” Id. at ¶17. Brainbuilders initiated the instant action to recover payment for services it allegedly rendered to a patient, a fourteen-year-old child (the “Child”), who has been diagnosed with an autism spectrum disorder. Id. at ¶¶2, 9.1 In May 2017, Brainbuilders began providing ABA

services to the Child, who was diagnosed with an ASD in 2009, and continues to do so to this day. Id. at ¶9. The Child’s mother is employed by the DOE and receives insurance coverage through her employer, as does the Child, as her dependent. Id. at ¶¶10, 11, 14. According to the New York Defendants, and not disputed by Plainitff, the DOE and the City of New York are New York municipal corporations. See ECF No. 13-1, Declaration of Judy E. Nathan, dated October 20, 2020 (“Nathan Decl.”), ¶3 (“The City is a municipal corporation organized pursuant to the laws of

1 Plaintiff’s Complaint refers to the child and mother involved on whose behalf Brainbuilders initiated this action as “D” and “H.” This Opinion refers to them as the Mother and the Child. the State of New York”); ECF No. 13-2, Declaration of Dean S. Weltman, dated October 20, 2020 (“Weltman Decl.”) ¶3 (“DOE, also known as the Board of Education of the City of New York, is a municipal corporation, organized and existing under Article 52-A of the New York Education Law, with its principal place of business located in the City, County, and State of New York.” ).

The OLR is a New York City agency which represents the Mayor of the City of the New York in labor relations between New York City and labor unions representing New York City employees. Weltman Decl. ¶3. It is also the agency which administers employee health benefits. Id. The DOE offers a variety of plans, and the Mother chose, and is insured by, the GHI Comprehensive Benefit Plan (the “Plan”), which is provided by defendants EmblemHealth, Inc. and Group Health Incorporated. Id. at ¶¶3, 4, 14. The Plan includes out-of-network services, and Brainbuilders is an out-of-network provider under the Plan. Id. at ¶16. The Mother uses the Plan to pay for the ABA health services provided by Brainbuilders. However, Plaintiff alleges that “GHI has been paying Brainbuilders approximately 6% of its billed amount for D’s ABA. Six-percent is well below Brainbuilders’ cost, forcing it to ‘balance bill’

[the Child’s] caregivers for the rest.” Id. at ¶21. Plaintiff alleges that “[i]n the State of New York, GHI, like all insurance companies, is required to provide coverage for the screening, diagnosis, and treatment of ASDs, including, but not limited to, ABA,” and that the Plan purportedly includes coverage for ABA. Id. at ¶18-19. But, in Plaintiff’s view, the Plan’s low reimbursement rate “fails to cover the ABA in any meaningful sense,” in violation of New York State law. Id. at ¶21. On behalf of herself and the Child, the Mother executed an assignment of benefits and an assignment of the right to pursue legal and administrative remedies under the Plan, appointing Rochel Sorotzkin, as their attorney-in-fact, with authority to pursue all legal and administrative remedies under their health insurance plan. Id. at ¶1-2.2 Dissatisfied with the reimbursement rate, Brainbuilders, as Plaintiff’s assignee, unsuccessfully initiated an internal appeal at GHI, according to the Plan’s internal appeal

procedures. Id. at ¶28. Thereafter, “a Notice of Claim was served on behalf of [the Mother] upon NYC Defendants in accordance with New York’s General Municipal Law. More than thirty-days has elapsed since such service, and NYC Defendants have refused to pay said claim or adjust the same.” Id. at ¶30. Thereafter, Plaintiff initiated the instant action asserting breach of contract, breach of the implied covenant of good faith and fair dealing, promissory estoppel, fraud, civil conspiracy, civil aiding and abetting claims, and violations of the New York Prompt Pay Law, New York Consumer Protection Law, the New York Autism mandate, and seeking a declaratory judgment. Plaintiff initially filed this action in New Jersey state court, and it was removed to this Court in September 2020. Then, the New York Defendants and GHI filed their respective motions to dismiss the Complaint. See ECF. Nos. 11, 13. On November 9, 2020, Plaintiffs filed an Amended Complaint. See ECF No. 16. Thereafter, the Court granted Defendants’ joint request to deem the pending motions to dismiss to be directed against Plaintiffs’ Amended Complaint. See ECF No. 18.

II. STANDARD OF REVIEW

2 The Power of Attorney provides that the Mother, appoints Rachel Sorotzkin as her “true and lawful agent (hereinafter my "Agent"), for all purposes related to health insurance, health benefits and/or insurance reimbursement to which I and/or my dependents may be or may become entitled with regard to services rendered to me and/or my dependents by BRAINBUILDERS LLC, and in connection therewith to perform such acts for me and on my behalf as my Agent, in my Agent's absolute discretion, deems advisable, as fully and with the same validity as I could if I did so personally in any jurisdiction in which my Agent shall act.” See ECF No. 23-1, Pl.

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BRAINBUILDERS LLC v. EMBLEMHEALTH, INC., Counsel Stack Legal Research, https://law.counselstack.com/opinion/brainbuilders-llc-v-emblemhealth-inc-njd-2021.