Highmark West Virginia, Inc. v. Jamie, 221 W. Va. 487

Summary

The Supreme Court of Appeals of West Virginia reviewed the dismissal of Dr. Sharooz Jamie’s second amended counterclaim in a dispute over alleged health-insurance overpayments and billing practices. The court held that Counts 1 through 4, alleging contract-related claims and fraud, were sufficiently pleaded to survive a Rule 12(b)(6) motion, while Counts 5 through 9 were properly dismissed. The dismissal was therefore affirmed in part, reversed in part, and remanded for further proceedings.

Holdings

1. An appellate court reviews a Rule 12(b)(6) dismissal de novo and should not dismiss a claim unless it appears beyond doubt that the claimant can prove no set of facts in support of the claim that would entitle the claimant to relief.
2. Counts 1 through 3 adequately stated claims arising from the Participation Agreement and should not have been dismissed under Rule 12(b)(6).
3. Count 4 adequately alleged fraud and should not have been dismissed under Rule 12(b)(6).
4. Counts 5 through 9 were insufficient under Rule 12(b)(6) and remained dismissed with prejudice.

Questions Presented

1. Whether the circuit court properly dismissed Counts 1 through 9 of Dr. Jamie's Second Amended Counterclaim under West Virginia Rule of Civil Procedure 12(b)(6).
2. Whether Counts 1 through 3 adequately alleged claims arising from the Participation Agreement for purposes of surviving a motion to dismiss.
3. Whether Count 4 adequately pleaded fraud with the particularity required by West Virginia Rule of Civil Procedure 9(b).
4. Whether Counts 5 through 9 stated legally sufficient claims for fraudulent underpayment, fraudulent charging of deductibles or copayments, negligence, or defamation.

Disposition

reversed_and_remanded