Elite Center for Minimally Invasive Surgery, LLC v. Health Care Service Corp.

221 F. Supp. 3d 853, 2016 WL 6236328, 2016 U.S. Dist. LEXIS 146849
CourtDistrict Court, S.D. Texas
DecidedOctober 24, 2016
DocketCIVIL ACTION NO. 4:15-CV-00954
StatusPublished
Cited by11 cases

This text of 221 F. Supp. 3d 853 (Elite Center for Minimally Invasive Surgery, LLC v. Health Care Service Corp.) is published on Counsel Stack Legal Research, covering District Court, S.D. Texas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Elite Center for Minimally Invasive Surgery, LLC v. Health Care Service Corp., 221 F. Supp. 3d 853, 2016 WL 6236328, 2016 U.S. Dist. LEXIS 146849 (S.D. Tex. 2016).

Opinion

Order of Adoption

Lynn N. Hughes, United States District Judge

On October 4, 2016, Magistrate Judge Stephen Wm. Smith issued a memorandum and recommendation (Dkt. 54) to which the defendant objected (Dkt. 24). After considering the record and the law, the court overrules the objections and adopts the memorandum and recommendation as its memorandum and opinion. Defendant’s motion to dismiss is granted as to Elite’s § 502(c) statutory penalty claims and common law promissory estoppel claims, but denied as to Elite’s claims for benefits under ERISA § 502(a)(1)(B) and state contract law.

MEMORANDUM AND RECOMMENDATION

Stephen Wm Smith, United States Magistrate Judge

Before the Court is defendant Health Care Service Corporation’s motion to dismiss plaintiff Elite’s second amended complaint. Dkt. 51. The motion should be granted in part and denied in part.

[856]*856BACKGROUND

This is an action by a Houston area medical provider (Elite) against a health insurance company (HCSC) challenging the denial or underpayment of nearly 1,500 separate health care claims submitted on behalf of insured patients from 2010 through 2012. Invoking both the federal Employee Retirement Income Security Act and state common law, Elite seeks to recover nearly $30 million allegedly due under the patients’ ERISA and non-ERISA plans.

Elite’s current complaint1 alleges four causes of action seeking: (1) benefits due under ERISA § 502(a)(1)(B) [29 U.S.C. § 1132(a)(1)(B)]; (2) statutory penalties under ERISA § 502(c) [29 U.S.C. § 1132(c) ] for failing to provide claim denial information; (3) damages for breach of contract; and (4) promissory estoppel. HCSC has moved to dismiss all counts for failure to state a claim under Federal Rule of Civil Procedure 12(b)(6).

ANALYSIS

In considering a 12(b)(6) motion to dismiss, the court must accept as true all well-pleaded facts and view the allegations in a light most favorable to the non-mov-ant. Sullivan v. Leor Energy, LLC, 600 F.3d 542, 546 (5th Cir. 2010). While the complaint is not required to contain detailed factual allegations, it must plead sufficient facts to state a claim to relief that is “plausible on its face.” Bell All. Corp. v. Twombly, 550 U.S. 544, 547, 127 S.Ct. 1955, 167 L.Ed.2d 929 (2007). The court reviews the complaint, documents attached to the complaint, and any documents accompanying the motion to dismiss that are referenced by the complaint. Lone Star Fund V (U.S.), L.P. v. Barclays Bank PLC, 594 F.3d 383, 387 (5th Cir. 2010).

Count One: ERISA § 502(a)(1)(B) Claim for Benefits Due

ERISA § 502(a)(1)(B) authorizes a suit by plan participant or beneficiary “to recover benefits due under the terms 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.” (Emphasis added). The existence of an employee welfare benefit plan is thus an essential element of a claim for benefits under § 502(a)(1)(B), and must be sufficiently pled to survive a Rule 12(b)(6) challenge. See Smith v. Reg’l Transit Auth., 756 F.3d 340, 345-47 (5th Cir. 2014). ERISA 3(1) defines an “employee welfare benefit plan” as:

[A]ny plan, fund, or program which was heretofore or is hereafter established or maintained by an employer or by an employee organization, or by both, to the extent that such plan, fund, or program was established or is maintained for the purpose of providing for its participants or their beneficiaries, through the purchase of insurance or otherwise, (A) medical, surgical, or hospital care or benefits ...

29 U.S.C. § 1002(1). The existence of a “plan, fund, or program” is established “ ‘if from the surrounding circumstances a reasonable person can ascertain the intended benefits, a class of beneficiaries, the source of financing, and procedures for receiving benefits.’” Mem’l Hosp. Sys. v. Northbrook Life Ins. Co., 904 F.2d 236, 240-41 (5th Cir. 1990) (quoting Donovan v. Dillingham, 688 F.2d 1367, 1373 (11th Cir. 1982).

[857]*857In Count One, Elite alleges that HCSC is responsible for denying or underpaying 1159 claims submitted . under ERISA plans during the relevant time period. See Dkt. 48, ¶ 27 n.7. Exhibit A, attached to the complaint, provides the date of submission, insurance and group identification numbers, charges, and payments for each claim submitted to HCSC from 2010-2012. Dkt. 48-1. Elite alleges that it has derivative standing to sue on behalf of plan participants based on assignments executed by each patient before services were rendered. Dkt. 48, ¶ 35. Elite specifically identifies only two ERISA plans by name (the “Halliburton Plan” and the “Texas Instruments Plan”), covering just two of the 1,159 ERISA claims. Id, at ¶¶ 37-38. For the rest, Elite generally alleges that these plans are “representative of the larger universe” of plans covering the remainder of the ERISA claims. Id. at ¶ 39.

HCSC’s motion urges that this count is insufficiently pled because it specifically identifies only two ERISA plans covering just two of the 1,159 separate ERISA claims listed in the complaint. Dkt. 48, ¶¶37, 38. HCSC contends that Elite has offered no good faith basis for alleging that the reimbursement provisions of these two plans are representative of the remaining un-named ERISA plans.

There is no question that, in at least these two instances, Elite has alleged an ERISA plan sufficient to support a § 502(a)(1)(B) claim. In each case the complaint names the plan, the plan sponsor, the employer, the covered employee, the plan administrator, and the claims administrator. The complaint also quotes the relevant plan language describing the “reasonable and customary” reimbursement standard which HCSC allegedly breached, not only in these two cases, but in the remainder as well. These allegations are definite enough to plead an ERISA plan under the Dillingham test adopted by the Fifth Circuit, and HCSC does not really contest the point. Instead, it focuses on the lack of particular allegations concerning the remaining plans.

It is true that Elite offers only a bare-bones assertion that the Halliburton, and Texas Instruments plans are “representative of • the larger universe” of plans at issue, but that does not render the assertion improbable. After all, HCSC is an insurance company in the business of selling and administering its health insurance plans, and Elite alleges each claim denial at issue involved an HCSC-administered policy or plan.

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221 F. Supp. 3d 853, 2016 WL 6236328, 2016 U.S. Dist. LEXIS 146849, Counsel Stack Legal Research, https://law.counselstack.com/opinion/elite-center-for-minimally-invasive-surgery-llc-v-health-care-service-txsd-2016.