NJSR Surgical Center, L.L.C. v. Horizon Blue Cross Blue Shield of New Jersey, Inc.

979 F. Supp. 2d 513, 57 Employee Benefits Cas. (BNA) 1132, 2013 WL 5781496, 2013 U.S. Dist. LEXIS 153630
CourtDistrict Court, D. New Jersey
DecidedOctober 24, 2013
DocketCiv. No. 12-753 (KM)
StatusPublished
Cited by23 cases

This text of 979 F. Supp. 2d 513 (NJSR Surgical Center, L.L.C. v. Horizon Blue Cross Blue Shield of New Jersey, 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
NJSR Surgical Center, L.L.C. v. Horizon Blue Cross Blue Shield of New Jersey, Inc., 979 F. Supp. 2d 513, 57 Employee Benefits Cas. (BNA) 1132, 2013 WL 5781496, 2013 U.S. Dist. LEXIS 153630 (D.N.J. 2013).

Opinion

OPINION

KEVIN McNULTY, District Judge.

Plaintiffs are health care providers; Defendants are health care insurers or administrators of health insurance claims. Plaintiffs allegedly rendered medical care to persons who were insured under Defendants’ plans. The Third Amended Complaint (referred to herein as the “Complaint”) alleges that Defendants wrongfully denied, underpaid, or simply disregarded the patients’ claims for reimbursement. Plaintiffs sue as alleged assignees of their patients’ right to pursue payment under the health insurance plans.

Some of the health plans at issue are self-insured plans governed by the Employee Retirement Income Security Act (ERISA). As to these ERISA plans, Plaintiffs seek compensatory damages and attorneys’ fees from the plan provider under ERISA, 29 U.S.C. § 1132(a)(1)(B) and § 1132(g)(1). Other health plans at issue are fully-insured non-ERISA plans. As to those non-ERISA plans, Plaintiffs assert state law claims for breach of contract.

Claims and Defendants

The Complaint has three counts. Count 1 is brought under Section 502(a)(1)(B) of ERISA, 29 U.S.C. § 1132(a)(1)(B). Count 2 is brought under Section 502(g)(1) of ERISA, 29 U.S.C. § 1132(g)(1). Count 3 is a state law claim for breach of contract. Count'3 is seemingly intended as a backstop or catchall for all claims brought under non-ERISA plans. See Complaint ¶ 35.

The Defendants named in the Complaint are:

Horizon Blue Cross Blue Shield of New Jersey, Inc. (“Horizon”)
New Jersey Transit Corporation (“NJT”)
Anthem Health Plans, Inc. (“Anthem”) County of Passaic
CareFirst of Maryland, Inc. (“Care-First”)
HealthNow New York, Inc.
City of Jersey City (“Jersey City”)
Orange-Ulster School District Health Plan
Plus fictitious parties,
Non-New Jersey BCBS Home Plans 1-10;
ABC Self-Funded Plans 1-10

[516]*516NJT and CareFirst filed the motions to dismiss that are currently before the Court.

Confusingly, the Complaint lumps together the actions of Defendants. Each count, moreover, lists only the Defendants to whom it is not directed. Count 1 and Count 2, both ERISA claims, state that they are “not directed to NJ Transit or Jersey City.” Count 3 states that it is “not directed to Anthem or CareFirst.”

Logically, an individual insurer might sponsor an ERISA plan, a non-ERISA plan, or possibly both. From this, I might surmise that the Venn-diagram organization of this Complaint is intended to reflect that in some way. Farther than that I cannot go.

One Defendant, Horizon Blue Cross, may only have allegedly acted as an administrative servicer. It is identified as a “health service corporation.” (Complaint ¶ 8) The only other allegations specifically referring to Horizon state that it provided administrative services for the twenty unidentified fictitious Defendants. (Complaint ¶¶ 16, 17). Again, it is difficult to know what to make of this.

Defendants NJT and Jersey City are explicitly excluded from the ERISA counts. That would tend to imply that they are alleged to have been involved only in non-ERISA plans. NJT and Jersey City each face a single count of common law breach of contract (Count 3 of the Complaint). NJT has moved to dismiss the single claim against it pursuant to Federal Rule of Civil Procedure 12(b)(1). NJT argues that this Court does not possess subject matter jurisdiction over such a claim because, by statute, a claim against this state entity can be brought only in state court. For the reasons discussed below, I will grant this motion.

CareFirst and Anthem are explicitly excluded from the non-ERISA count, Count 3. That would tend to imply that CareFirst and Anthem are alleged to have been involved only in ERISA plans. They are named only in Counts 1 and 2 of the Complaint, the ERISA counts. CareFirst and Anthem moved to dismiss the ERISA claims against them, pursuant to Federal Rule of Civil Procedure 12(b)(6). Anthem has withdrawn its motion, leaving only CareFirst. CareFirst also seeks a more definite statement pursuant to Federal Rule of Civil Procedure 12(e). CareFirst argues that the complaint inadequately pleads (a) that the Plaintiffs possess derivative standing to bring ERISA claims assigned to them by their patients; and (b) that plaintiffs have exhausted administrative remedies or that exhaustion would be futile.

Because the Complaint’s allegations of derivative standing are insufficient, I grant Care First’s 12(b)(6) motion in part, but afford Plaintiffs leave to file an amended complaint. CareFirst’s 12(e) motion for a more definite statement is denied. Frankly, however, this Complaint is vulnerable. When drafting their amended complaint, Plaintiffs would do well to specify which Defendants did what, which, plan was involved, and the basis for resulting liability.

The motions are decided without oral argument. See Fed.R.Civ.P. 78(b).

DISCUSSION

A. NJT’s Rule 12(b)(1) Motion to Dismiss

NJT, one of two Defendants facing only state law claims, is named only in Count Three, the breach of contract count. NJT moves to dismiss the complaint pursuant to Rule 12(b)(1). NJT argues that, as a State entity, it cannot be sued for breach of contract in federal court, citing the New Jersey Contractual Liability Act (“CLA”), N.J. Stat. Ann. § 59:13-4.

[517]*517Motions pursuant to Federal Rule of Civil Procedure 12(b)(1) to dismiss a complaint for lack of subject matter jurisdiction may be raised at any time. Iwanowa v. Ford Motor Co., 67 F.Supp.2d 424, 437-38 (D.N.J.1999). Rule 12(b)(1) challenges may be either facial or factual attacks. Mortensen v. First Fed. Sav. & Loan Ass’n, 549 F.2d 884, 891 (3d Cir.1977). “A motion to dismiss on the basis of Fed.R.Civ.P. 12(b)(1) for lack of subject matter jurisdiction made prior to the filing of the defendant’s answer is a facial challenge to the complaint.” Bennett v. Atlantic City, 288 F.Supp.2d 675, 678 (D.N.J.2003) (citing Mortensen, 549 F.2d at 891). A facial challenge asserts that the complaint does not allege sufficient grounds to establish subject matter jurisdiction, Iwanowa, 67 F.Supp.2d at 438; Lennox Underground Found., Inc. v. Geron, 2013 WL 632121, *2-3, 2013 U.S. Dist. LEXIS 22879, *6-8 (D.N.J.

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979 F. Supp. 2d 513, 57 Employee Benefits Cas. (BNA) 1132, 2013 WL 5781496, 2013 U.S. Dist. LEXIS 153630, Counsel Stack Legal Research, https://law.counselstack.com/opinion/njsr-surgical-center-llc-v-horizon-blue-cross-blue-shield-of-new-njd-2013.