Neurological Surgery, P.C. v. Travelers Co.

243 F. Supp. 3d 318, 2017 U.S. Dist. LEXIS 154948, 2017 WL 1133291
CourtDistrict Court, E.D. New York
DecidedMarch 21, 2017
Docket15-cv-6843 (SJF)(AYS)
StatusPublished
Cited by19 cases

This text of 243 F. Supp. 3d 318 (Neurological Surgery, P.C. v. Travelers Co.) is published on Counsel Stack Legal Research, covering District Court, E.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Neurological Surgery, P.C. v. Travelers Co., 243 F. Supp. 3d 318, 2017 U.S. Dist. LEXIS 154948, 2017 WL 1133291 (E.D.N.Y. 2017).

Opinion

OPINION AND ORDER

FEUERSTEIN, District Judge:

On October 29,2015, plaintiffs Neurological Surgery, P.C. (“Neurological”) and William J. Sónstein, M.D. (“Sonstein”) (together, “Plaintiffs”) commenced this action against defendant Travelers Company (“Travelers”) by filing a summons with notice in the Supreme Court of the State of New York, County of Nassau. In their summons with notice, Plaintiffs,. a Long Island-based neurological surgery medical practice and a physician affiliated with-the practice, described the nature of their action as one asserting claims under the Employee Retirement Income and Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001 et seq,, and various state-law causes.of action. Plaintiffs sought at least $278,278.68 in damages for Traveler’s “failure to timely and properly pay in full claims submitted to [Travelers] by Plaintiffs for medical health care services Plaintiffs provided to [Travelers’] employees pursuant to a health benefits plan adminis[321]*321tered by [Travelers] for the benefit of .its employees and others.” On December 1, 2015, Travelers removed the action to this Court, invoking this Court’s jurisdiction under section 502(e) of ERISA, 29 U.S.C. § 1132(e). ■

On January 14, 2016, Plaintiffs filed a complaint in this Court, asserting seven causes of action: 1) recovery of benefits due under an ERISA insurance plan, pursuant to 29 U.S.C. § 1132(a)(1)(B); 2) recovery of attorneys’ fees and costs under ERISA, pursuant to 29 U.S.C; § 1132(g)(1); 3) breach of contract; 4) breach of implied-in-fact contract; 6) unjust enrichment; 6) violation of New York Insurance Law § 3224-a (the “Prompt Pay Law”); and 7) breach of third-party-beneficiary contract. On April 8, 2016, Travelers moved to dismiss Plaintiffs’ ERISA claims pursuant to Rule 12(b)(6) for lack of statutory standing and, • alternatively, for failure to plead a breach of the ERISA plan. Travelers moved to dismiss Plaintiffs’ state law claims pursuant to Federal Rule of Civil Procedure 12(b)(6) on the grounds that they are preempted by ERISA and, alternatively, that Plaintiffs’ failed to adequately plead facts supporting such claims. (Dkt, 12)'.1 For the following reasons, Travelers’ motion,is granted insofar as Plaintiffs’ ERISA claims are dismissed for lack of statutory standing and denied insofar as the Court concludes that Plaintiffs’ state law claims are not -preempted by ERISA and declines to exercise supplemental jurisdiction over those claims.

1. BACKGROUND2

A. Out-of-Network Medical Services and the Allegedly Deficient Payment

Neurological is a Long Island-based neurological surgery practice with offices throughout Long Island and in Manhattan, and Sonstein is a New York-licensed phy[322]*322sician employed by Neurological. (See Complaint (“Compl.”) (Dkt. 6) ¶¶ 1-3, 13, 14). Travelers, a corporation organized under the laws of Minnesota with its principal place of business in New York City, “is one of the nation’s largest property casualty companies ..., with more than 30,000 employees, 13,000 independent agents, and multiple market segments across the personal, business, financial and international insurance groups.” (Id. ¶¶4, 15). “[A] substantial number of Travelers’ employees receive health benefits through á benefits plan administered and funded by Travelers, which is a benefit plan established pursuant to [ERISA].” (Id. ¶5).3 While Travelers funds and administers the Plan, Blue Cross and Blue Shield of Minnesota (“BCBS Minnesota”) functions as the Plan’s claims administrator. (See Plan at 1, 5, 15). Plaintiffs allege that, as the Plan’s funder and administrator, Travelers “make[s] determinations regarding [P]lan interpretation, coverage, the awarding or denial of benefits, the processing and determination of appeals, and the payment of benefits.” (Id. ¶ 22).

The Plan distinguishes between “in-network” healthcare providers, which have contracts with BCBS Minnesota and/or other Blue Cross and Blue Shield affiliates across the country, with out-of-network providers, which do not. (Compl. ¶¶ 7—8; Plan at 1, 8, 9, 84). For example, the Plan notes that, while “[m]ost In-Network [Providers] have agreed to accept as full payment ... an amount that [BCBS Minnesota] has negotiated with its In-Network Providers,” “[w]hen [a Plan participant] use[s] an Out-of-Network Provider, benefits are substantially reduced and [the Plan participant] will likely incur significantly higher out-of-pocket expenses.” (Plan at 8, 9). Neurological, by its own choice, is a non-participating, out-of-network provider in the networks of BCBS Minnesota, Empire HealthChoice HMO, Inc. (“Health-Choice HMO”), Empire HealthChoice Assurance (“HealthChoice Assurance”), and/or Blue Cross and Blue Shield of New York (“BCBS NY’), which Plaintiffs refer to collectively, as “Empire.” (Compl. ¶¶ 1, 10,28).

Plaintiffs allege that “[a] number of Neurological[’s] .., patients have health insurance coverage from Empire, through their employer, Travelers, or are members, subscribers, or beneficiaries of plans for which Travelers is the plan sponsor or administrator.” (Id. ¶21). Plaintiffs-allege that, “[n]otwithstanding its status as an Empire non-participating provider, Neurological ... routinely receives authorization and assignments from its patients who are Travelers employees or their eligible family members to receive payment directly from Travelers, through its agent Empire, for the medical services that Neurological ... and its physicians render to Travelers employees and their eligible family members.” (Id. ¶ 10). One such patient is MA, the spouse of a Traveler’s employee and a Plan beneficiary, to whom Neurological provided “medically necessary health services in connection with MA’s diagnosis of displacement of the lumbar intervertebral disc without myelopathy,” on March 12, 2013. (Id. ¶ 48; see id. ¶¶1, 11, 49-51).

Plaintiffs allege that “[o]n or around March 27, 2013, Neurological sent Empire a bill in the amount of $285,900” for the medical services it had provided to MA, but that Neurological “only received $7,621.32 on this claim, far below what Empire, acting as Travelers’ agent, was obligated to pay.” (Id. ¶¶ 51, 53). Plaintiffs do not specify from whom Neurological [323]*323received $7,621.32. Plaintiffs allege that, “[p]ursuant to the terms of the relevant Travelers health plan documents and agreements, Empire, acting as Travelers’ agent was obligated to reimburse Neurological ... in full—or at the very least at a usual, customary, or reasonable amount— for medically, necessary health care services provided to MA,” but that Travelers has refused to do so. (Id. ¶¶ 51, 53). The Plan provides that “[f]or services received from an Out-of-Network Provider ..., the allowed [amount] will be [based on one of five calculation methods], to be determined by [BCBS Minnesota] at its discretion.” (Plan at 9).

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Cite This Page — Counsel Stack

Bluebook (online)
243 F. Supp. 3d 318, 2017 U.S. Dist. LEXIS 154948, 2017 WL 1133291, Counsel Stack Legal Research, https://law.counselstack.com/opinion/neurological-surgery-pc-v-travelers-co-nyed-2017.