RENÉE MARIE BUMB, District Judge.
This matter comes before the Court upon the filing of a motion by Defendant Health Care Service Corporation, a Mutual Legal Reserve Company, doing business in Texas as Blue Cross and Blue Shield of Texas (incorrectly identified as Blue Cross Blue Shield of Texas) ("HCSC" or "Defendant") [Dkt. No. 38] seeking the dismissal of all counts of Plaintiff Rahul Shah, M.D.'s ("Plaintiff" or "Dr. Shah") Amended Complaint pursuant to Fed. R. Civ. P. 12(b)(6). For the reasons stated herein, the motion will be granted, in part, and denied, in part.
On February 16, 2015, Dr. Shah performed spinal surgery (the "Procedures") on his patient, Dennis C. (the "Patient"). (Am. Compl. ¶ 4-5). Dr. Shah obtained an assignment of benefits from the Patient so that he could bring claims under the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1002, et seq. ("ERISA") on the Patient's behalf. (Am. Compl. ¶6; Am. Compl. Ex. B).
After performing the Procedures, and pursuant to the assignment of benefits, Dr. Shah prepared a Health Insurance Claim Form ("HICF") demanding reimbursement in the amount of $162,466.00 from Defendant, the claims administrator of the Patient's health insurance plan. (Am. Compl. ¶ 7, 15; Am. Compl. Ex. C). Defendant, however, paid only a fraction of the requested amount. (
Unsatisfied with the amount of reimbursement he received, Dr. Shah instituted an administrative appeal, pursuing a full reimbursement. (
On October 4, 2016, Plaintiff filed a four count complaint in the New Jersey Superior Court, Civil Division, Cumberland County (No. CUM-L-699-16) against Horizon Blue Cross Blue Shield of New Jersey ("Horizon") and Defendant alleging: (1) breach of contract; (2) failure to make all payments pursuant to member's plan under 29 U.S.C. § 1132(a)(1)(B); (3) breach of fiduciary duty and co-fiduciary duty under 29 U.S.C. § 1132(a)(3), 29 U.S.C. § 1104(a)(1), and 29 U.S.C. § 1105(a); and (4) failure to establish/maintain reasonable claims procedures under 29 C.F.R. 2560.503-1. [Dkt. No. 1-1]. Defendant removed the action to federal court on November 28, 2016 on the basis of federal question jurisdiction.
On March 10, 2017, Plaintiff dismissed his claims against Horizon without prejudice. [Dkt. No. 23]. On May 4, 2017, he filed the Amended Complaint restating the four counts of the initial complaint and adding two additional counts against Defendant: (1) failure to establish a summary plan description in accordance with 29 U.S.C. § 1022 and 29 C.F.R. § 2520.102-2 and (2) failure to provide a copy of the summary plan description upon written request in violation of 29 U.S.C. § 1024. (Am. Compl. ¶ 51-68).
Pursuant to this Court's Individual Rules and Procedures, the Defendant filed a letter on June 16, 2017 expressing its intention to file a motion to dismiss Plaintiff's Complaint and setting forth its arguments in support of that proposed motion. [Dkt. No. 33]. In response, Plaintiff indicated that he would voluntarily dismiss Counts One (breach of contract) and Six (29 U.S.C. § 1024). [Dkt. No. 36]. Defendant filed the pending motion to dismiss on July 12, 2017, seeking the dismissal of all of the remaining claims. [Dkt. No. 38].
To withstand a motion to dismiss under Federal Rule of Civil Procedure 12(b)(6), "a complaint must contain sufficient factual matter, accepted as true, to `state a claim to relief that is plausible on its face.'"
Rule 12(b)(6) requires the district court to "accept as true all well-pled factual allegations as well as all reasonable inferences that can be drawn from them, and construe those allegations in the light most favorable to the plaintiff."
At the outset, the Court notes that Counts One (breach of contract) and Six (29 U.S.C. § 1024) are dismissed with prejudice in accordance with the Plaintiff's concessions that his contract claim is preempted by ERISA and that Defendant, as a claims—rather than plan—administrator is not the proper party against which to bring a claim for failure to furnish a summary plan description. [Dkt. No. 36]. Consistent with these concessions, and pursuant to the Court's directive, [Dkt. No. 37], these Counts were not included in Defendant's motion or briefed by the parties.
Defendant seeks the dismissal of each of the remaining claims. As to Count Two, HCSC argues that only a plan itself or a plan administrator can be liable for wrongful denial of benefits under 29 U.S.C. § 1132 ("ERISA § 502"), and that as a claims administrator it is not a proper defendant for such a claim. Defendant argues that Count Three (ERISA fiduciary duty claim) should be dismissed for two reasons. First, Defendant argues that the statute only permits equitable relief, and that Plaintiff seeks only legal relief. Second, Defendant argues that because Plaintiff seeks only legal relief, the fiduciary duty claim must be dismissed as duplicative of Count Two, which alleges a failure to make all payments under ERISA. Finally, Defendant argues that Counts Four (failure to establish or maintain reasonable claims procedures) and Five (failure to establish a summary plan description) should be dismissed because the regulations relied upon by Plaintiff in bringing these claims do not provide private causes of action.
The Court will address Defendant's arguments seriatim.
In Count Two of the Amended Complaint, Plaintiff seeks to recover, via ERISA § 502(a)(1)(B), the difference between the reimbursement he requested and the amount paid by Defendant, among other relief. Defendant contends that "[t]he proper defendant in a claim for wrongful denial of benefits under ERISA § 502(a)(1)(B) is the plan itself or a person who controls the administration of benefits under the plan." (Def.'s Br. at 3). Since HCSC is merely the claims administrator, and not the plan administrator, it argues that it is not a proper defendant under ERISA § 502 and that this claim should be dismissed. At this juncture, the Court disagrees.
ERISA § 502 provides that "[a] civil action may be brought. . . by a participant or beneficiary . . . to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan." 29 U.S.C. § 1132(a)(1)(B). The Third Circuit has stated, in distinguishing who may be sued under ERISA § 502(a)(1)(B) and § 502(a)(2), that "in a § 1132(a)(l)(B) claim, the defendant is the plan itself (or plan administrators in their official capacities only)."
Plaintiff alleges that it was Defendant who was responsible for the decision not to fully reimburse him. (Am. Compl. ¶ 3, 7, 8, 16, 28, 31, 40). Moreover, Plaintiff appended a copy of the "Summary Plan Description" ("SPD") to the Amended Complaint as Exhibit F.
This Court cannot find that regardless of its role and responsibilities under the plan, HCSC is immune from liability under ERISA §502(a)(1)(B) simply because of the title given to it under this contract. In order to determine whether Defendant is the proper party to face such a suit, the Court looks to the issue of "control over the administration of benefits."
In Count Three of the Amended Complaint, Plaintiff alleges that HCSC breached a fiduciary duty and co-fiduciary duty owed to Plaintiff and seeks redress via 29 U.S.C. § 1132(a)(3)(B) ("ERISA § 502(a)(3)"), 29 U.S.C. § 1104(a)(1) and 29 U.S.C. § 1105(a). Defendant argues that Count Three should be dismissed because Plaintiff seeks legal relief, and only equitable relief is available under ERISA for a breach of fiduciary duty. Moreover, Defendant argues that Plaintiff's fiduciary duty claims merely restate his claim for wrongful denial of benefits and are thus duplicative of Count Two. Plaintiff argues, among other things, that dismissal of these claims at this stage would be premature. The Court agrees.
Plaintiff alleges that HCSC breached its fiduciary duties by
(Am. Compl. ¶ 41). Through this claim, Plaintiff seeks various remedies, including reimbursement for benefits allegedly owed under the plan and "such other and further relief as the Court may deem just and equitable." (
ERISA § 502(a)(3) is a "general `catchall' provision[ that]. . . act[s] as a safety net, offering appropriate equitable relief for injuries caused by violations that § 502 does not elsewhere adequately remedy."
The Supreme Court has not held—and neither has the Third Circuit—that
At the appropriate stage of the litigation, however, "the Court will not permit a [breach of fiduciary duty] claim to duplicate the relief theories of [a benefits claim]. . . ."
In Count Four, Plaintiff asserts a claim for failure to establish or maintain reasonable claims procedures under 29 C.F.R. § 2560.503-1. Defendant argues that this claim should be dismissed because it is "well-established" that 29 C.F.R. § 2560.503-1 is simply a "regulatory device" which "does not provide for a private right of action, let alone a right to monetary damages." (Def. Br. at 5). Plaintiff seemingly concedes that he is not entitled to monetary relief, but contends that Defendant's argument for dismissal is "incomplete" because it does not address Plaintiff's requests for equitable relief in the form of "an Order that Defendants have not established and maintained claims procedures that comply with 29 C.F.R. § 2560.503-1, and that as a result Plaintiff is deemed to have exhausted all required administrative remedies" and "such other and further relief as the Court may deem just and equitable." (Pl.'s Br. at 7; Am. Compl. ¶ 50).
As to monetary relief, this Court has held—and other courts have consistently done the same—that neither 29 C.F.R. § 2560.503-1 nor 29 U.S.C. § 1133 (ERISA § 503), the statutory provision it accompanies, gives rise to a private cause of action.
Plaintiff's requests for "equitable relief" pursuant to 29 C.F.R. § 2560.503-1 fare no better. As noted above, in addition to monetary relief, in the Wherefore Clause of Count Four of the Amended Complaint, Plaintiff requests "an Order that Defendants have not established and maintained claims procedures that comply with 29 C.F.R. § 2560.503-1, and that as a result Plaintiff is deemed to have exhausted all required administrative remedies" and "such other and further relief as the Court may deem just and equitable." (
Violations of 29 C.F.R. § 2560.503-1 may be probative of issues under ERISA § 502, but do not, in and of themselves, give rise to a cause of action. Accordingly, Defendant's motion to dismiss Count Four of the Amended Complaint will be granted, and Count Four will be dismissed, with prejudice.
In Count Five, Plaintiff asserts a claim for failure to establish a Summary Plan Description ("SPD") in accordance with 29 U.S.C. § 1022 (ERISA § 102) and 29 C.F.R. 2520.102-2. Defendant argues that Count Five should be dismissed because ERISA § 102 does not provide a cause of action for failure to establish an SPD.
Plaintiff alleges that "the employee benefit plan is not written in a manner calculated to be understood by the average plan participant and it has the effect of failing to inform its participants and beneficiaries." (Am. Compl. ¶ 57). Specifically, Plaintiff avers that "the summary plan description states that the patient's cost-sharing obligation for out-of-network outpatient surgery is 40% without explaining what 40% refers to (i.e. 40% of what?)," thereby "insinuat[ing] that out-of-network outpatient surgery is reimbursed at 60% of the provider's charges." (
Defendant cites to
As recognized by the court in
Moreover, the Court will not decide at this juncture whether Count Five "fits under § 502." Plaintiff plead a violation of §102 and its accompanying regulation. This Court will not rewrite Plaintiff's Complaint. If Plaintiff wishes to amend his pleadings for a second time, he should seek leave to do so.
For the foregoing reasons, Defendant's motion to dismiss the Amended Complaint will be denied, in part, and granted, in part. The motion to dismiss Counts Two and Three of the Amended Complaint will be denied, without prejudice. The motion to dismiss Counts Four and Five will be granted, and Counts Four and Five will be dismissed, with prejudice.
An accompanying Order shall issue on this date.