Semente v. Empire Healthchoice Assurance, Inc.

147 F. Supp. 3d 117, 2015 U.S. Dist. LEXIS 162941, 2015 WL 7953939
CourtDistrict Court, E.D. New York
DecidedDecember 4, 2015
Docket14 CV 5823 (DRH) (SIL)
StatusPublished
Cited by4 cases

This text of 147 F. Supp. 3d 117 (Semente v. Empire Healthchoice Assurance, Inc.) 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
Semente v. Empire Healthchoice Assurance, Inc., 147 F. Supp. 3d 117, 2015 U.S. Dist. LEXIS 162941, 2015 WL 7953939 (E.D.N.Y. 2015).

Opinion

MEMORANDUM AND ORDER

HURLEY, Senior District Judge:

Plaintiff Raymond A. Semente, D.C., P.C. (“plaintiff’ or “Semente”) brings this action against defendants Empire Health-choice Assurance, Inc. d/b/a Empire Blue Cross Blue Shield, (“Empire”), Verizon (Communications, Inc., Verizon Advanced Data, Inc., Verizon Avenue Corp., Verizon Corporate Services Corp., Verizon New York Inc., Verizon New England Inc., Verizon Services Corp., Empire City Subway Company (Limited), (collectively, the “Verizon defendants”), and County of Suffolk, Suffolk County Labor/Management Committee,- and the Employee Medical Health Plan of Suffolk County (collectively, “Suffolk” or “defendants”). Plaintiff is a corporation providing chiropractic and related medical services, which commenced .this action on behalf of its patients to recover money allegedly wrongfully withheld by Empire and the health plans it administers for Verizon and Suffolk employees.

Count I of the Complaint asserts claims against Empire and Verizon defendants pursuant to the Employee Retirement Income Security Act (“ERISA”), 28 U.S.C. [119]*119§ 1332(a)(1)(B). Count II of the Complaint asserts a claim for breach of the Employee Medical Health Plan. (“EMH Plan”) administered by Empire and sponsored by Suffolk as well as violations of 29 C.F.R. § 2560.503-1, as developed more fully below. Count III asserts , a claim against Empire and Suffolk for violation of New York’s Prompt Pay Law.1

Presently before the Court is Suffolk’s motion to dismiss for lack of-standing pur; suant to Federal Rule of Civil Procedure (“Rule”) 12(b)(1) .and for failure to state a claim pursuant to Rule 12(b)(6).. - For .the reasons set forth below, Suffolk’s motion to dismiss is granted in part and denied ,in part.

BACKGROUND

The following facts are taken from the Complaint. • .

At all relevant times, plaintiff provided medically necessary and appropriate chiropractic and related medical services to patients who were, at the time services were rendered, either employees, retirees, 'covered spouses and/or dependents under Suffolk’s ‘EMH Plan (“Plan Patients”). Plaintiff was an out-of-network provider under the EMH Plan. Plaintiff claims that the Patient Protection and Affordable Care Act (“PPACA”) governs thé EMH Plan at issue because that plan is a government-sponsored plan not covered by ERISA. However, plaintiff claims that the PPACA incorporated the ERISA regulation set forth at C.F.R. § 2560.5034 (“the Regulation”), which sets forth certain requirements for the claims procedures of group health plans, including the -timing and content of notification of benefit determinations. Indeed, the PPACA provides that “a group health plan and a health insurance issuer offering group health coverage shall provide an internal claims and appeals, process that initially incorporates the claims and appeals procedures ... set forth at section 2560.503-1 of title 29, Code of Federal Regulations.” 42 U.S.C. § 300gg-19(a)(2)(A);

Between 2005 and October 2013, plaintiff submitted benefit claims to Empire for reimbursement with respect to chiropractic and related medical services plaintiff provided to EMH Plan Patients. By letter dated October 28, 2013, however, Empire advised plaintiff that for all future claims, medical records would be required to be submitted to Empire at the inception of every claim, meaning that such records must accompany every initial claim form for services. Plaintiff complied with this requirement. However, since October of 2013, Empire, on behalf of Suffolk County, has refused to render payment to plaintiff for the benefit claims made under the EMH Plan. Plaintiff claims that these denials along with the medical records requirement were “in violation of the terms of the applicable EMH Plan, in violation of [Suffolk’s] fiduciary duties, and in violation of the governing Regulation.” (ComplJ 97.)

The Assignments

Plaintiff claims to have obtained written authority from Plan Patients to represent them in commencing and pursing this lawsuit on their behalf. The authorizations are entitled “Assignment of Causes of Action and Right ■ to Pursue Litigation on Behalf of Health Plan Employee Members and Dependents” and state as follows:

I hereby assign to Dr. Raymond A. Se-menté, D.C., P.C. any and all legal causes of action and the right to commence and pursue a lawsuit on my behalf and/or on behalf of the employee member and/or all covered persons or [120]*120dependents under the group health plan issued by the County of Suffolk, New York to pursue payment to me or the employee member for health plan claims that have been denied or partially unpaid by the health plan issued by [the County] to pursue payment to me or the employee member for health plan claims that have been denied or partially unpaid by the health plan and/or its administrator, Empire Blue Cross Blue Shield, for services rendered to me and/or my dependents or the covered employee under the health plan. I hereby authorize such lawsuit to be commenced and pursued against the .County of Suffolk and/or any of its subdivisions and/or the Employee Medical Health Plan of Suffolk County and Empire Blue Cross Blue Shield.

(Comply 84.)

DISCUSSION

I. Standard of Review for Motion to Dismiss

In 'deciding a Rule 12(b)(6) motion to dismiss, the Court applies a “plausibility standard,” which is guided by “[t]wo working principles.” Ashcroft v. Iqbal, 556 U.S. 662, 678, 129 S.Ct. 1937, 173 L.Ed.2d 868 (2d Cir.2009) (citing Bell Atl. Corp. v. Twombly, 550 U.S. 544, 127 S.Ct. 1955, 167 L.Ed.2d 929 (2007); accord Harris v. Mills, 572 F.3d 66, 71-72 (2d Cir.2009). First, although the Court must accept all allegations as true, this “tenet” is “inapplicable to legal conclusions;” thus, “[threadbare recitals of the elements of a cause of action, supported by mere conclusory statements, do not suffice.” Iqbal, 556 U.S. at 678, 129 S.Ct. 1937; accord Harris, 572 F.3d at 72. Second, only complaints that state a “plausible claim for relief’ can survive a Rule 12(b)(6) motion to dismiss. Iqbal, 556 U.S. at 679, 129 S.Ct. 1937. Determining whether a complaint does so is “a context-specific task that requires the reviewing court to draw on its judicial experience and common sense.” Id.; accord Harris, 572 F.3d at 72.

In making its determination, the Court is confined to “the allegations contained within the four corners of [the] complaint.” Pani v. Empire Blue Cross Blue Shield, 152 F.3d 67, 71 (2d Cir.1998).

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Cite This Page — Counsel Stack

Bluebook (online)
147 F. Supp. 3d 117, 2015 U.S. Dist. LEXIS 162941, 2015 WL 7953939, Counsel Stack Legal Research, https://law.counselstack.com/opinion/semente-v-empire-healthchoice-assurance-inc-nyed-2015.