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12(b)(6) Ruling: D.N.J.

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  • 12(b)(6) Ruling: D.N.J.

    In a recent case from New Jersey, the court twice dismisses Plaintiff's Complaint, while giving Plaintiff a final opportunity to amend.

    In the prior Opinion, I held that the original allegations, as pled in the initial Complaint, failed to assert sufficient facts to state a plausible claim for wrongful denial of benefits under § 502(a)(1)(B). In that connection, although Plaintiff alleged that Defendants failed to pay the “usual and customary charge” for the out-of-network services of which he was a recipient, Plaintiff did not identify a specific provision in the Plan obligating Defendants to provide compensation at that rate for out of network services. Atl. Plastic & Hand Surgery, PA, 2018 U.S. Dist. LEXIS 47181, at *29. Therefore, the Court found, as pled, Plaintiff failed to identify a provision in the Plan that would entitle him to additional benefits at the “usual and customary rate” for out-of-network medical services, and, as a result, Plaintiff’s § 502(a)(1)(B) claim was dismissed without prejudice.
    The court then reviews Plaintiff's First Amended Complaint, which added additional facts, but did not persuade the court:

    Here, the facts pled in the First Amended Complaint allow the Court to reasonably infer that the treatment which Plaintiff received for “a severe infection,” immediately upon his
    admission to the Emergency Department at Riverview Medical Center, constitutes “Emergency Services” under the Plan. Am. Compl. ¶ 44. In this regard, Plaintiff alleges facts referencing particular provisions in the Plan obligating Defendants to pay certain benefits in connection with out-of-network Emergency Services. As stated, these provisions set forth the procedures by which Defendants are required to ascertain the appropriate rate of compensation for out-ofnetwork Emergency Services, including the maximum allowable amount being the greatest of the following: (a) amount negotiated with Network Providers for the Emergency Service furnished; (b) amount calculated using the method the Administrator generally uses to determine payments for Out-of-Network services, subject to the substitution of certain related costs; or (c)amount paid under Medicare for the Emergency Service. Id. ¶ 44. However, although Plaintiff has identified the provisions which might entitle him to additional benefits for out-of-network services under the Plan, his additional allegations, nonetheless, fail to assert a cognizable § 502(a)(1)(B) claim. Indeed, Plaintiff does not allege how Defendants’ payment of $3,501.60 falls below the “maximum allowed” rate for out-of-network services under the Plan.3 Nor does Plaintiff allege, at a minimum, that Defendants acted in contravention of the procedures for determining out-ofnetwork benefits. Instead, Plaintiff merely references them in the First Amended Complaint, without articulating how the pertinent provisions of the Plan entitle him to additional compensation. Accordingly, based on these deficiencies, the Court finds that Plaintiff’s First Amended Complaint—which solely points to relevant provisions in the Plan but fails to allege what amount Plaintiff should be entitled to under those provisions—does not assert a viable claim under § 502(a)(1)(B). Complete Foot & Ankle v. Cigna Health & Life Ins. Co., No. 17- 13742, 2018 U.S. Dist. LEXIS 82650, at *3 (D.N.J. May 16, 2018) (“[T]he Complaint contains little more than an assertion that Plaintiff is owed more than it was paid for the services it provided. This is insufficient . . . .”); Lemoine v. Empire Blue Cross Blue Shield, No. 16-6786, 2018 U.S. Dist. LEXIS 62535, at *16 (D.N.J. April 12, 2018) (dismissing the plaintiff’s 501(a)(1)(B) claim, because the plaintiff, among other things, failed to demonstrate “how [the pertinent provisions of the plan] were violated”). Nevertheless, while Plaintiff’s amended § 501(a)(1)(B) claim is dismissed, to the extent that Plaintiff can demonstrate that he is entitled to additional benefits pursuant to the Plan provisions by which out-of-network rates are determined, the Court grants Plaintiff a final opportunity to amend his Complaint.
    As aforementioned, the court ultimately grants Defendant's Motion to Dismiss, but provides the Plaintiff with a final opportunity to properly amend his Complaint. The entire opinion is attached below.
    Attached Files