Frankel, M.D. v. U.S. Healthcare, Inc.

CourtDistrict Court, S.D. New York
DecidedSeptember 17, 2019
Docket1:18-cv-06378
StatusUnknown

This text of Frankel, M.D. v. U.S. Healthcare, Inc. (Frankel, M.D. v. U.S. Healthcare, Inc.) is published on Counsel Stack Legal Research, covering District Court, S.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Frankel, M.D. v. U.S. Healthcare, Inc., (S.D.N.Y. 2019).

Opinion

UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK

PERRY A. FRANKEL, M.D. and ADVANCED CARDIOVASCULAR DIAGNOSTICS, PLLC,

Plaintiffs,

OPINION AND ORDER -against- 18 Civ. 06378 (ER)

U.S. HEALTHCARE, INC., d/b/a AETNA U.S. HEALTHCARE, INC., d/b/a AETNA HEALTH, INC., and AETNA, INC., d/b/a AETNA,

Defendants.

Ramos, D.J.:

Perry A. Frankel, M.D. and Advanced Cardiovascular Diagnostics, PLLC (“Plaintiffs”), bring this action against U.S. Healthcare, Inc., d/b/a Aetna U.S. Healthcare, Inc., d/b/a Aetna Health, Inc. and Aetna, Inc., d/b/a Aetna (“Defendants” or “Aetna”), alleging breach of contract, breach of the implied covenant of good faith and fair dealing, promissory estoppel, unjust enrichment, tortious interference with a contract, and various violations of New York State and federal law, including the Patient Protection and Affordable Care Act (the “ACA”), 42 U.S.C. § 80001 et seq., and the Health Insurance Portability and Accountability Act’s (“HIPAA”) Privacy Rule, 45 C.F.R. § 164.502. Before the Court is Defendants’ motion to dismiss all claims, and Plaintiffs’ motion to amend their complaint. Doc. 28; Doc. 32. For the reasons set forth below, this Court GRANTS in part and DENIES in part Defendants’ motion to dismiss under Federal Rule of Civil Procedure 12(b)(6), and DENIES Plaintiffs’ motion to amend the complaint under Federal Rule of Civil Procedure 15(a)(2). I. BACKGROUND A. Plaintiffs’ Complaint Perry A. Frankel, a New York State-licensed physician, entered into a Specialist Physician Agreement (the “Agreement”) with Aetna in April 1998. Compl. ¶ 7. Under the terms

of the Agreement, Dr. Frankel was to provide covered services to Aetna plan enrollees, members and beneficiaries (“Members”) at a mutually agreed upon contractual rate. Id. ¶ 9. Dr. Frankel and his practice, Advanced Cardiovascular Diagnostic, provide cardiovascular testing and prevention services at both traditional settings throughout the State and in two “fully-equipped mobile medical offices” (“Mobile Clinics”). Id. ¶ 3. Plaintiffs use the Mobile Clinics to reach Members who would otherwise not have access to cardiovascular care, including union workers and employees of government agencies, churches, and charitable organizations. Id. ¶¶ 10, 12-15. Plaintiffs also use the Mobile Clinics to reach “Members in underserved urban populations in New York City.” Id. ¶ 13. In 2017, Defendants took two actions that prompted this case: first, they adopted a new

policy of no longer covering services provided at the Mobile Clinics; then, they exercised their right of non-renewal to terminate their Agreement with Plaintiffs. On May 4, 2017, Defendants first sent Plaintiffs an e-mail alerting them that they would no longer be covering services provided at the Mobile Clinics. Id. ¶ 22. Plaintiffs responded to Defendants’ e-mail on June 6, 2017, disputing the decision. Id. ¶ 23. On June 19, 2017, Defendants began a pre-payment audit review for claims submitted for services rendered at the Mobile Units and halted payment for claims totaling over $900,000. Id. ¶ 24. On September 25, 2017, Defendants sent Plaintiffs a notice alerting them that they would not be renewing their contract the following April. Id. ¶ 25. The notice indicated that this decision was due to Aetna “rationalizing its network.” Ex. D, Letter from Terry Golash, M.D., Senior Medical Director, Metro New York, to Dr. Perry Frankel (Sept. 25, 2017). Plaintiffs appealed the decision in February 2018. The appeal was unsuccessful, and Defendants again gave the same reason for non-renewal. Compl. ¶ 26. Plaintiffs brought suit shortly thereafter.

B. The Agreement According to the Agreement, “Covered Services” are “[t]hose Medically Necessary Services which a Member is entitled to receive under the terms and conditions of a Plan.” Ex. A, Specialist Physician Agreement § 12.4. “[Aetna] . . . shall have final authority to determine whether any services provided by Provider were Covered Services and to adjust or deny payments for services rendered by Provider to Members in accordance with the results of such determinations.” Id. § 1.1. With regards to the parties’ relationship, the Agreement establishes in relevant part that Providers are considered independent contractors and that Aetna’s “medical management procedures, protocols, and policies do not dictate or control Provider’s clinical decisions with

respect to the medical care or treatment of Members.” Id. § 9.1. Additionally, Providers must make records available to Aetna upon request. Id. §§ 6.3-6.4. The Agreement may be terminated in several ways, including by non-renewal “upon any anniversary of the Effective Date, provided that the party desiring not to renew this Agreement provides at least sixty (60) days prior written notice of such non-renewal to the other party.” Id. § 7.2. The Agreement is governed by New York Law and imposes a statute of limitations of twelve months for causes of action “regardless of form, arising out of or related to th[e] Agreement.” Id. § 11.3. C. Procedural History Plaintiffs first filed suit against Defendants in New York Supreme Court on May 25, 2018, asserting nine causes of action. Defendants removed the case to federal court in July 2018 on the grounds that the complaint was completely preempted by the Employee Retirement

Income Security Act of 1974 (ERISA), 29 U.S.C. § 1001 et seq., and because some of Plaintiffs’ allegations arose under federal law, namely the ACA. The motion was unopposed. On August 21, 2018, Plaintiffs amended their complaint, adding two new causes of action. The eleven causes of action asserted in the current complaint are as follows: • Count I: Breach of the implied covenant of good faith and fair dealing • Count II: Violation of New York General Business Law § 349 • Count III: Breach of contract • Count IV: Violation of the ACA and New York Public Health Law § 4406(1) • Count V: Promissory estoppel • Count VI: Unjust enrichment • Count VII: Tortious interference with contract • Count VIII: Violation of New York Insurance Law § 3224-a • Count IX: Violation of New York Public Health Law §§ 4406-d and New York Insurance Law § 4803(b)(1) • Count X: Violation of Title VI, as incorporated by the ACA • Count XI: Violation of the Health Insurance Portability and Accountability Act (HIPAA)

On November 5, 2018, Defendants filed the instant motion to dismiss Plaintiffs’ complaint in its entirety for failure to state a claim under Federal Rule of Civil Procedure 12(b)(6). Doc. 28. In response, Plaintiffs oppose some but not all of these arguments1 and request permission to amend their complaint for a second time under Federal Rule of Civil Procedure 15(a)(2). Doc. 32 at 6.

1 Specifically, Plaintiffs do not contest Defendants’ non-ERISA arguments with regards to Counts II, IV, VI, VIII, IX, X, and XI and therefore concede that these counts fail. See In re UBS AG Sec. Litig., No. 07 Civ. 11225 (RJS), 2012 WL 4471265, at *11 (S.D.N.Y. Sept. 28, 2012) (arguments not addressed in opposition are conceded). II. DEFENDANTS’ MOTION TO DISMISS A.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Paneccasio v. Unisource Worldwide, Inc.
532 F.3d 101 (Second Circuit, 2008)
Foman v. Davis
371 U.S. 178 (Supreme Court, 1962)
Aetna Health Inc. v. Davila
542 U.S. 200 (Supreme Court, 2004)
Bell Atlantic Corp. v. Twombly
550 U.S. 544 (Supreme Court, 2007)
Ashcroft v. Iqbal
556 U.S. 662 (Supreme Court, 2009)
Halebian v. Berv
644 F.3d 122 (Second Circuit, 2011)
Williams v. Citigroup Inc.
659 F.3d 208 (Second Circuit, 2011)
Koch v. Christie's International PLC
699 F.3d 141 (Second Circuit, 2012)
Gatt Communications, Inc. v. PMC Associates, L.L.C.
711 F.3d 68 (Second Circuit, 2013)
Cruz v. FXDirectDealer, LLC
720 F.3d 115 (Second Circuit, 2013)
Harrison v. NBD INC.
990 F. Supp. 179 (E.D. New York, 1998)
ICD Holdings S.A. v. Frankel
976 F. Supp. 234 (S.D. New York, 1997)
Klos v. Haskell
835 F. Supp. 710 (W.D. New York, 1993)
White Plains Coat & Apron Co. v. Cintas Corp.
867 N.E.2d 381 (New York Court of Appeals, 2007)
511 West 232nd Owners Corp. v. Jennifer Realty Co.
773 N.E.2d 496 (New York Court of Appeals, 2002)

Cite This Page — Counsel Stack

Bluebook (online)
Frankel, M.D. v. U.S. Healthcare, Inc., Counsel Stack Legal Research, https://law.counselstack.com/opinion/frankel-md-v-us-healthcare-inc-nysd-2019.