Summary
The United States District Court for the District of New Jersey considers UnitedHealthcare Insurance Company’s motion to dismiss claims arising from payment for an out-of-network breast reconstruction procedure. The court declines to find Samra Plastic and Reconstructive Surgery’s New Jersey contract, promissory estoppel, and account-stated claims preempted by ERISA and allows those claims to proceed. The court concludes that Patient A.M.’s ERISA-based claims are inadequately pleaded.
Topics
Practice areas
Questions Presented
- Whether the court could consider disputed and allegedly unauthenticated pre-authorization correspondence on a Rule 12(b)(6) motion.
- Whether Samra's state-law claims were expressly preempted by ERISA.
- Whether Samra plausibly pleaded breach of contract, promissory estoppel, and account stated.
- Whether Patient plausibly pleaded an ERISA claim for benefits under 29 U.S.C. § 1132(a)(1)(B).
- Whether Patient plausibly pleaded ERISA fiduciary-duty and summary-plan-description claims.
Holdings
- The court would not consider the pre-authorization correspondence attached to the motion because its authenticity and relationship to the alleged contract were factually disputed.
- As pleaded, Samra's breach-of-contract, promissory-estoppel, and account-stated claims were not expressly preempted by ERISA § 514.
- Samra plausibly pleaded all three state-law claims, including an agreement or promise to pay the FH75 rate and a definite unpaid balance.
- Patient failed to state a claim for ERISA benefits because she did not identify a specific plan provision requiring UnitedHealthcare to pay the billed charges or claimed balance.
- Patient failed to state an ERISA fiduciary-duty or co-fiduciary-duty claim because she sought only monetary damages and did not identify appropriate equitable relief.
- Patient failed to state a claim under 29 U.S.C. §§ 1022 and 1132(c)(1)(B) because she did not allege that UnitedHealthcare was the plan administrator.
Key quotations
“The Court, in viewing the allegations in the light most favorable to Samra as it must, see Phillips, 515 F.3d at 228, finds that Samra adequately pleads a breach of contract claim.” (at 10)
“Because Patient fails to allege a specific Plan term that provides for payment of such fees, Patient’s claim must be dismissed.” (at 16)
“The Court, accordingly, grants Defendant’s Motion to Dismiss Count Five.” (at 18)
Factual background
Samra, an out-of-network New Jersey healthcare provider, performed a second-phase breast reconstruction procedure for Patient A.M., who was insured by UnitedHealthcare. Before the procedure, Samra alleged that UnitedHealthcare authorized specified CPT codes and agreed to pay at the FAIR Health 75th-percentile benchmark. Samra billed $51,600, but UnitedHealthcare paid $5,311.03, leaving an alleged balance of $46,288.97.
Procedural history
Plaintiffs initially filed the action in New Jersey state court, and UnitedHealthcare removed it to the District of New Jersey. The complaint asserted state-law claims for breach of contract, promissory estoppel, and account stated on behalf of Samra, and ERISA claims on behalf of Patient A.M. The court granted the motion to dismiss the ERISA claims, denied dismissal of the state-law claims, and declined to consider disputed and unauthenticated pre-authorization correspondence at the pleading stage.