v.
BLUE CROSS BLUE SHIELD OF FLORIDA
Plaintiff LI Neuroscience Specialists ("plaintiff" or "LI Neuroscience") filed this action against defendant Blue Cross Blue Shield of Florida ("defendant" or "BCBS"), seeking the full amount of its billed charges for medical care provided to a beneficiary of defendant, Barton W. ("the patient"), alleging that it is entitled to recover this amount because the patient transferred all of his rights to benefit payments under his insurance plan, as well as all related rights under the Employee Retirement Income Security Act of 1974 ("ERISA"), to plaintiff.
Presently before the Court is defendant's motion to dismiss the Complaint, pursuant to Rule 12(b)(6) of the Federal Rules of Civil Procedure, on the following grounds: (1) plaintiff lacks standing to pursue this claim under ERISA because the assignment of benefits was invalid; and (2) plaintiff fails to state a claim under ERISA for any relief. For the reasons set forth below, the motion to dismiss is granted.
In particular, the Court dismisses the Complaint because the Court finds that the unambiguous anti-assignment provision in the Plan document nullified any purported assignment of the patient's benefits to plaintiff and because plaintiff does not seek equitable relief such that a claim for breach of fiduciary duty under ERISA would be proper. However, because plaintiff asserted at oral argument that it is considering pursuing an alternative standing argument using a power of attorney theory, the Court will conduct a status conference to determine whether plaintiff wishes to seek leave to re-plead in light of the Court's decision.
I. BACKGROUND
A. The Complaint[1]
According to the Complaint, plaintiff provided emergency medical services to [*350] the patient on August 16, 2013, the value of which was $ 214,925. (Compl. ¶¶ 3-6, 8.) The patient was a beneficiary of defendant's health care plan and policies ("the Plan"). (Id. ¶ 2.) Plaintiff asserts that the patient transferred all of his rights under his insurance plan and all of his related rights under ERISA to plaintiff. (Id. ¶ 7.) Plaintiff did not attach the alleged assignment to the Complaint or its opposition papers, nor do any of plaintiff's filings specify the terms of the assignment.
As the purported assignee of the benefits, plaintiff prepared Health Insurance Claim Forms demanding reimbursement in the amount of $ 214,925 for the emergency medical services rendered to the patient, and defendant subsequently issued reimbursement in the amount of $ 12,257.90 and indicated that an additional $ 850.54 was the patient's coinsurance liability. (Id. ¶¶ 8-9.) Plaintiff then exhausted the administrative appeals process maintained by defendant. (Id. ¶ 10.)
Plaintiff contends that pursuant to § 502(a)(1)(B) of ERISA, codified at
Plaintiff further alleges a cause of action pursuant to ERISA § 502(a)(3), codified at
Although the Complaint does not state the basis for BCBS's authority, other than to allege that BCBS was the patient's health insurer, defendant has not challenged that that the relevant Plan is a health and welfare benefit plan under ERISA, and the patient was a Plan participant. Additionally, the Court notes that plaintiff seeks identical relief under both its breach of contract claim and its equitable relief claim.
B. The Plan
Defendant appended a copy of the relevant Plan document to its motion to dismiss, along with a declaration by its attorney declaring that the provided plan document was the pertinent benefits plan for the patient here. The relevant provision related to assignment of benefits states:
Except as set forth in the last paragraph of this section, we will not honor any of the following assignments, or attempted assignments, by you to any Provider:
• an assignment of the benefits due to you for Covered Services under this Benefit Booklet;
• an assignment of your right to receive payments for Covered Services under this Benefits Booklet; or
• an assignment of a claim for damage resulting from a breach, or an alleged breach, of the Group Master Policy.
We specifically reserve the right to honor an assignment of benefits or payment by you to a Provider who: 1) is In-Network under your plan of coverage; 2) is a NetworkBlue Provider even if that [*351] Provider is not in the panel for your plan of coverage; 3) is a Traditional Program Provider; 4) is a BlueCard® (Out-Of-State) PPO Program Provider; or 5) is a BlueCard® (Out-of-State) Traditional Program Provider.
(Plan, ECF No. 13-3, at 38.)
C. Procedural History
Plaintiff filed its Complaint on December 27, 2017. (ECF No. 1.) On March 7, 2018, defendant moved to dismiss the Complaint pursuant to Federal Rule of Civil Procedure 12(b)(6). (ECF No. 13.) Plaintiff opposed the motion on March 22, 2018, and defendant filed its reply in support of the motion on April 6, 2018. (ECF Nos. 16-17.) The Court heard oral argument on the motion on May 22, 2018. (ECF No. 20.) Defendant submitted supplemental authority on the issue of the enforceability of anti-assignment provisions on November 28, 2018 and January 14, 2019. (ECF Nos. 21-22.) Plaintiff did not respond to the supplemental submissions. To date, Barton W., the patient, has not participated in this case. The Court has fully considered all of the parties' submissions and arguments.
II. STANDARD OF REVIEW [2]
When a court reviews a motion to dismiss for failure to state a claim for which relief can be granted, it must accept the factual allegations set forth in the complaint as true and draw all reasonable inferences in favor of the plaintiff. See Cleveland v. Caplaw Enters. ,
The Supreme Court clarified the appropriate pleading standard in Ashcroft v. Iqbal , setting forth a two-pronged approach for courts deciding a motion to dismiss.
The Court notes that in adjudicating a Rule 12(b)(6) motion, it is entitled to consider: "(1) facts alleged in the complaint and documents attached to it or incorporated in it by reference, (2) documents 'integral' to the complaint and relied upon in it, even if not attached or incorporated by reference, (3) documents or information contained in defendant's motion papers if plaintiff has knowledge or possession of the material and relied on it in framing the complaint, (4) public disclosure documents required by law to be, and that have been, filed with the Securities and Exchange Commission, and (5) facts of which judicial notice may properly be taken under Rule 201 of the Federal Rules of Evidence." In re Merrill Lynch & Co. ,
III. DISCUSSION
Defendants argue that the Complaint fails to state a claim for which relief can be granted because: (1) plaintiff lacks a cause of action under ERISA to bring a claim under § 502 because the assignment of benefits was invalid; (2) plaintiff fails to state a claim under § 502(a)(1)(B) because plaintiff fails to identify any plan term entitling it to relief; and (3) plaintiff fails to state a claim under § 502(a)(3) because the claim is duplicative of the claim under § 502(a)(1)(B) and impermissibly seeks legal relief where Congress only authorized equitable remedies. For the reasons set forth below, the Court concludes that plaintiff does not have a cause of action to bring a claim pursuant to § 502(a)(1)(B) because the unambiguous anti-assignment provision in the Plan nullified any purported assignment of benefits under the plan, including the right to bring a claim under § 502(a)(1)(B). Because the Court concludes that plaintiff does not have a cause of action to pursue a claim under § 502(a)(1)(B), the Court need not address whether plaintiff has alleged sufficient facts to state a claim under that provision. Further, the Court concludes that plaintiff's § 502(a)(3) claim impermissibly seeks legal relief in the form of money damages where Congress only authorized equitable relief, and therefore, that claim must be dismissed.
A. ERISA § 502(a)(1)(B)
1. Legal Standard
ERISA § 502(a)(1)(B) clearly provides that a civil action may be brought to [*353] recover benefits due under the terms of a plan, to enforce rights under the terms of the plan, or to clarify rights to future benefits under a plan (1) "by a participant or beneficiary" of (2) an ERISA employee benefit plan.
In order for plaintiff to have a cause of action under ERISA based on an assignment of benefits, the purported assignment of benefits must be valid. See Neurological Surgery, P.C. v. Travelers Co. ,
In McCulloch Orthopaedic Surgical Services, PLLC v. Aetna Inc. , the Second Circuit concluded that based on the plain language of an anti-assignment provision in an ERISA health care plan, an out-of-network healthcare provider's "acceptance of an assignment was ineffective-a legal nullity."
McCulloch ' s conclusion regarding the ineffectiveness of assignments of ERISA plan benefits where the plan contains an unambiguous anti-assignment provision is in accord with other circuits. See Am. Orthopedic & Sports Medicine v. Independence Blue Cross Blue Shield ,
[*354] Davidowitz v. Delta Dental Plan of Cal., Inc. ,
2. Application
Defendants argue that plaintiff does not have a cause of action under § 502(a)(1)(B) because plaintiff is neither a beneficiary of nor a participant in the Plan, and because the purported assignment of benefits from the patient to plaintiff is invalid because of the unambiguous anti-assignment clause in the Plan. Plaintiff does not dispute that the Plan contains an anti-assignment provision or that the anti-assignment provision is unambiguous, but rather argues that this Court should not enforce the anti-assignment provision "as a matter of policy, fairness, and common sense." (Pl. Opp., ECF No. 16, at 2.) As this Court is bound by the precedent set by the Second Circuit, the Court concludes that the unambiguous anti-assignment provision in the Plan is enforceable, and thus plaintiff does not have a cause of action to bring an ERISA enforcement claim pursuant to § 502(a)(1)(B).
As an initial matter, the Court agrees with defendant (and plaintiff) that the language of the anti-assignment provision in the Plan is unambiguous. "We interpret ERISA plans in an ordinary and popular sense as would a person of average intelligence and experience." Critchlow v. First UNUM Life Ins. Co. of Am. ,
Here, the language of the anti-assignment provision states as follows:
Except as set forth in the last paragraph of this section, we will not honor any of the following assignments, or attempted assignments, by you to any Provider:
• an assignment of the benefits due to you for Covered Services under this Benefit Booklet;
• an assignment of your right to receive payments for Covered Services under this Benefits Booklet; or
• an assignment of a claim for damage resulting from a breach, or an alleged breach, of the Group Master Policy.
(Plan, at 38.) The Court concludes that, giving the anti-assignment provision its "ordinary and popular meaning," the plain meaning of the anti-assignment provision is unambiguous. Notably, as previously discussed, plaintiff does not dispute that the provision is unambiguous. Thus, based on the plain and unambiguous language of the anti-assignment provision in the Plan at issue here, plaintiff's "acceptance of an assignment was ineffective-a legal nullity." McCulloch ,
Plaintiff argues that this Court should ignore the binding precedent of the Second Circuit and conclude that the assignment of benefits was valid despite the unambiguous anti-assignment provision in the Plan, because of public policy considerations. The primary case plaintiff cites in support of this argument is Hermann Hospital v. MEBA Medical & Benefits Plan , relying on the statement of that court that it would be "inequitable" to enforce the anti-assignment provision at issue in that case because the assignee of benefits was "the provider of the very services which the plan is maintained to furnish."
In any event, to the extent Hermann could somehow be read more broadly to support plaintiff's argument, it is inconsistent with the Second Circuit's decision in McCulloch , which is binding on this Court. Plaintiff argues that McCulloch does not apply because the Second Circuit did not consider the policy arguments advanced in the instant case, and other circuits that have directly addressed policy arguments in the context of anti-assignment provisions "completely mistake the analysis." (Pl. Opp., at 5.) However, even assuming arguendo that such public policy arguments were persuasive (an issue which this Court does not reach), such considerations are irrelevant when binding precedent is controlling. See, e.g., United States v. Lenon ,
[*356] In sum, this Court, relying on the controlling authority of the Second Circuit, concludes that the unambiguous anti-assignment provision renders any assignment of benefits a legal nullity, and thus finds that plaintiff does not have a cause of action under ERISA § 502(a)(1)(3).
B. ERISA § 502(a)(3)
1. Legal Standard
Plaintiff argues that it is entitled to relief under ERISA § 502(a)(3), an equitable provision which allows "a participant, beneficiary, or fiduciary" to bring an action "to enjoin any act or practice which violates any provision of this subchapter or the terms of the plan, or ... to obtain other appropriate equitable relief ."
2. Application
Plaintiff asserts a cause of action pursuant to § 502(a)(3), seeking redress for defendant's alleged breach of fiduciary duty and/or breach of co-fiduciary duty, resulting from defendant's actions in denying payment for medical bills and in the handling of the administrative appeals initiated by plaintiff. Plaintiff seeks identical relief under the § 502(a)(3) claim as under its § 502(a)(1)(B) claim, in the form of orders directing defendant to reimburse plaintiff for the alleged underpayment in the amount of $ 201,816.56, an order directing defendant to pay plaintiff all benefits patient would be entitled to under the Plan, and for compensatory damages, attorneys' fees and costs, and any other relief the Court deems just and equitable. Defendant argues that (1) this claim is duplicative of plaintiff's claim under § 502(a)(1)(B), and (2) does not seek equitable relief, but rather is a "re-label[ed]" claim for contractual money damages. The Court agrees that plaintiff's claim under § 502(a)(3) seeks only compensatory, monetary relief, and should be dismissed.
Though plaintiff attempts to couch its § 502(a)(3) claim in equitable terms, plaintiff does not seek equitable relief-but rather, the essence of the claim is one for damages for alleged underpayment. See Frommert v. Conkright ,
Here, despite purportedly seeking equitable relief, the remedy sought is clearly legal in the form of money damages, because plaintiff "seek[s] no more than compensation for loss resulting from the defendant's breach of legal duty." Frommert ,
As in Frommert , plaintiff's claims here are couched in equitable terms, but the essence of plaintiff's claim in this case is one for monetary compensation, as reflected by the identical nature of the relief sought for both plaintiff's § 502(a)(3) claim and plaintiff's § 502(a)(1)(B) claim. Though plaintiff argues that it is improper to dismiss its § 502(a)(3) claim until it is determined whether plaintiff can succeed on its § 502(a)(1) claim (which the Court has already concluded it cannot, as plaintiff has no cause of action to bring the claim), or alternatively that "the monetary relief [p]laintiff seeks under [§ 502(a)(1)(B) ] is by definition separate and distinct from the monetary relief sought under [§ 502(a)(3) ]," the Court finds no merit to those arguments.
Plaintiff points to cases interpreting the Supreme Court's decision in Varity Corp. v. Howe ,
Here, the possibility of pursuing both claims simultaneously is not at issue, because the Court concludes that plaintiff is not seeking equitable relief at all, but rather seeks the balance of the billed and unreimbursed medical expenses-the exact same relief sought in plaintiffs § 502(a)(1)(B) claim. Because plaintiff seeks reimbursement for the balance of [*358] the charges for medical services provided (as well as other "classic" legal remedies such as compensatory damages), rather than any equitable remedy that could be awarded if plaintiff's § 502(a)(3) claim was successful, and plaintiff's equitable claim is clearly an effort to "repackage" its claim under § 502(a)(1)(B), the Court dismisses this claim.
C. Leave to Amend
In its opposition papers, plaintiff requested leave to re-plead if the claims were dismissed. At oral argument, plaintiff specifically noted the possibility of seeking leave to amend its Complaint to attempt to pursue a cause of action under ERISA as plaintiff's power of attorney. Because this issue was not briefed, and plaintiff did not have the Court's decision, the Court will conduct a status conference to discuss whether plaintiff will now seek leave to re-plead in light of the Court's decision.
IV. CONCLUSION
BCBS's motion to dismiss the Complaint in its entirety is granted. Plaintiff does not have a cause of action to pursue a claim under ERISA for any violation of § 502(a)(1)(B) because of the unambiguous anti-assignment provision in the Plan. Further, plaintiff's § 502(a)(3) claim against BCBS is dismissed because the relief sought is a purely legal, rather than equitable remedy. The parties shall participate in a telephone conference with the Court on Monday, March 11, 2019, at 4:30 p.m., to discuss whether plaintiff is seeking leave to file an amended complaint.
SO ORDERED.
The following facts are taken from the Complaint and are not findings of fact by the Court. Instead, the Court will assume the facts in the Complaint to be true for the purpose of the pending 12(b)(6) motion to dismiss.
The Court notes that "statutory standing" under ERISA, which defendant challenges in its motion, is properly analyzed under the Rule 12(b)(6) standard for failure to state a claim. See Am. Psychiatric Ass'n v. Anthem Health Plans, Inc. ,
As is discussed in more detail infra , plaintiff's claim is based upon an ERISA plan. Therefore, the plan documents submitted by BCBS are integral to plaintiff's complaint. See DeSilva v. North Shore-Long Island Jewish Health Sys. Inc. ,
Section 3(1) of ERISA defines an employee welfare benefit plan as "any plan, fund, or program which was heretofore or is hereafter established or maintained by an employer or by an employee organization, or by both, to the extent that such plan, fund, or program was established or is maintained for the purpose of providing for its participants or their beneficiaries ... benefits."