JOSEPH D. ALKON v. CIGNA HEALTH AND LIFE INSURANCE COMPANY

District Court, D. New Jersey·Decided August 3, 2021·No. 2:20-cv-02365·Unknown

Opinion

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW JERSEY

JOSEPH D. ALKON, M.D., PC, ON BEHALF OF PATIENT G.D., Plaintiff, Case No.: 2:20-cv-02365

v. OPINION CIGNA HEALTH AND LIFE INSURANCE COMPANY, AND FORWARD AIR CORPORATION PLAN, Defendants.

WILLIAM J. MARTINI, U.S.D.J.: This is an ERISA action concerning Defendants’ alleged under-reimbursement to Plaintiff, an out-of-network medical provider, for post-mastectomy breast reconstruction surgical services rendered to Patient G.D. Defendants CIGNA Health and Life Insurance Company (“CIGNA”) and Forward Air Corporation Benefit Plan (the “Plan”) moved to dismiss Plaintiff’s Complaint. ECF No. 21. On March 4, 2021, the Court granted Defendants’ motion and dismissed the matter with prejudice, reasoning that Plaintiff lacked ERISA standing to bring this matter on behalf of Patient G.D. On March 18, 2021, Plaintiff filed a motion for reconsideration of the Court’s March 4, 2021 Opinion and Order dismissing the case. ECF No. 32. Defendants filed an opposition. ECF No. 35. Plaintiff filed no reply. Before the Court, for the fourth time in one year, is the question of whether a designated authorized representative has standing under ERISA to challenge adverse benefits determinations in federal court where the patient’s plan contains an anti- assignment provision. Again, the Court concludes that the answer is no: Where a patient’s plan contains an anti-assignment provision, neither the patient’s assignment of benefits to nor a Designation of Authorized Representative naming a healthcare practice are bases for ERISA standing. For this reason, and because Plaintiff’s other arguments are without merit, the Court DENIES Plaintiff’s reconsideration motion. I. BACKGROUND1

On August 1, 2018, Patient G.D. (the “Patient”), who suffered from breast cancer, underwent a bilateral mastectomy with tissue expander at Trinitas Hospital in Elizabeth, New Jersey. Compl., ECF No. 1, ¶ 15. Dr. Joseph Alkon performed a two-stage, post- mastectomy breast reconstruction on the Patient on February 1, 2018 and August 20, 2018. Id. at ¶¶ 4, 15, 31. Plaintiff in this matter is Joseph D. Alkon, M.D., P.C., a medical practice group based in Linden, New Jersey, and Dr. Joseph Alkon is the Chief of Plastic Surgery at Trinitas Regional Medical Center. Id. at ¶ 12. Dr. Alkon and his practice are not part of CIGNA’s network of participating healthcare providers—Plaintiff and Dr. Alkon are “out- of-network.” Id. at ¶ 17. On the dates of service, the Patient was employed by Forward Air had health coverage through Defendant Plan administered by Defendant CIGNA. Id. at ¶ 2. There is no dispute that the Plan is an “employee welfare benefit plan” governed by and subject to the Employee Retirement Income Security Act of 1974 (“ERISA”). Plaintiff alleged that both stages of Patient’s surgery were preauthorized by CIGNA. Compl., ¶¶ 18, 31. Authorization B4371HK1 is a January 17, 2018 letter to the Patient stating: (1) that Trinitas Regional Medical Center is not a part of CIGNA’s network; (2) that CIGNA approved Trinitas’s request to cover the February 1, 2018 procedures; and (3) that the procedures would be covered at the “out-of-network level.” ECF No. 27-2, Ex. 1. Authorization B5HFCVK1 is an August 2, 2018 letter to the Patient regarding the August 20, 2018 procedure, stating that the procedure was approved. Id. Ex. 2. Neither authorization contains reimbursement rates or any other provision specifying payment terms. Following each stage of the Patient’s surgery, Plaintiff submitted invoices for its services to CIGNA. Id. at ¶¶ 19, 32. Together, those invoices totaled $292,084. Compl. at ¶¶ 19, 32, 65. The allowed out-of-network amount under the Patient’s Plan was $2,721.83. Id. at 19, 32, 66. According to Plaintiff, the difference between what Plaintiff billed and what the Plan paid left “an unreimbursed amount of $289,362.1[2].” Id. at ¶ 66. Plaintiff engaged in and exhausted the Plan’s administrative appeals seeking additional reimbursement, without success, arguing that because the network was allegedly inadequate, Dr. Alkon should have been granted an in-network exception. Id. at ¶¶ 23, 36, 38, ECF No. 27-2, Exs. 3, 4. By letter dated June 11, 2019, CIGNA told the Plan participant that CIGNA was “unable to approve coverage for the requested service(s) at the in-network benefit level. We have qualified network health care professional/facility which can provide services to you.” ECF No. 28, Ex. 1. Plaintiff received an Assignment of Benefits and a Designation of Authorized Representative from Patient G.D.. Id. at ¶¶ 38, 40. The Assignment of Benefits states, in relevant part: I hereby assign and convey to the fullest extent permitted by law any and all benefit and non-benefit rights (including the right to any payments) under

1 The facts are derived almost verbatim from the Court’s March 4, 2021 Opinion, which were in turn drawn from the Complaint, ECF No. 1. The parties do not appear to disagree on the facts of this dispute in a way that is material to Plaintiff’s reconsideration motion. my health insurance policy or benefit plan to Dr. Joseph Alkon and Joseph Alkon, M.D. (collectively, the “Providers”) with respect to any and all medical/facility services provided by the Providers to me for all dates of service. It is specifically intended by this assignment of benefits to assign . . . any and all of my rights, including without limitation . . . (iv) to bring any appeal, lawsuit or administrative proceeding, for and on my behalf, in my name against any person and/or entity involved in determination of benefits under any insurance policy or benefit plan. Id. at ¶ 39. The Designation of Authorized Representative stated, in relevant part: I hereby appoint as a Designated Authorized Representative each of my Providers and . . . lawyers (including the Law Offices of Cohen and Howard) . . . [including the] right of my Authorized representative to pursue . . . litigation or otherwise under any Federal or State law with respect to payment for services provided by a Provider to me, including penalties, interest, and attorney fees. Id. at ¶ 40. The Court derives the abridged language of the Assignment of Benefits and the Designation of Authorized Representative from Plaintiff’s Complaint because, although they are central to the arguments made in Plaintiff’s opposition to Defendants’ motion to dismiss and those arguments that are renewed on reconsideration, to the Court’s knowledge, the actual documents including these terms have at no time during this litigation been included as exhibits. The Patient’s Plan included the following clause, entitled Assignment and Payment of Benefits: You may not assign to any party, including, but not limited to, a provider or healthcare service/items, your right to benefits under this plan, nor may you assign any administrative, statutory, or legal rights or causes of action you may have under ERISA, including, but not limited to, any rights to make a claim for plan benefits, to request plan or other documents, to file appeals of denied claims or grievances, or to file lawsuits under ERISA. Any attempt to assign shall be void and unenforceable under all circumstances. . . . Pl.’s Mot. to Dismiss, Ex. A. 47, ECF No. 21-3. On March 5, 2020, Plaintiff filed a Complaint, seeking to recover the unreimbursed amount of its billed charges. ECF No. 1. In Count I, Plaintiff claimed that Defendant CIGNA, in violation of the Plan and 29 U.S.C. § 1132(a)(1)(B), ERISA § 502 (a)(1)(B), under-reimbursed Plaintiff for breast reconstruction surgeries. Id. at ¶¶ 63-67.

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