United States District Court, E.D. North Carolina, Western Division
TERRENCE W. BOYLE, UNITED STATES DISTRICT JUDGE.
cause comes before the Court on defendants' motion to
dismiss pursuant to Rule 12(b)(6) of the Federal Rules of
Civil Procedure. Plaintiff has responded, defendants have
replied, and a hearing on the matter was held before the
undersigned on November 9, 2017, at Raleigh, North Carolina.
In this posture, the motion is ripe for ruling. For the
reasons that follow, defendants' motion to dismiss is
filed this action under the Employee Retirement Income
Security Act of 1974 as amended, 29 U.S.C. § 1001,
et seq. (ERISA) and the state law of North Carolina.
Plaintiff is a specialized toxicology laboratory that offers
urine drug testing and monitoring services; patients who have
been prescribed pain medication are referred by their
physicians to plaintiff for testing and monitoring services.
Plaintiff provides drug testing and monitoring services to
many patients who are Cigna insureds, but plaintiff is not an
in-network provider with Cigna. Plaintiff thus requires each
Cigna insured patient to sign a form which provides the
following in a consent/insurance release provision:
I understand my signature requests that payment of authorized
insurance or Medicare benefits be made on my behalf to AvuTox
for the urine drug testing services furnished to me by the
physician. I acknowledge that AvuTox may be an out of network
facility with my insurance provider. I authorize any holder
of medical information about me to release to the insurance
company or to CMS (Centers for Medicare and Medicaid
Services), and its agents any information needed to determine
these benefits or the benefits payable to related services.
This assignment will remain in effect until revoked by me in
Cmp. Ex. B.
alleges that on or about August 31, 2015, it received a
letter from Cigna questioning plaintiffs billings practices
and the medical necessity of the services rendered by
plaintiff to Cigna insureds. Cigna stated that it had made
erroneous benefit payments to plaintiff on the claims of
various Cigna insureds in the amount of $2, 727, 118.08 and
demanded repayment. Plaintiff further alleges that Cigna
falsely accused it of engaging in fee-forgiveness programs
and otherwise waiving the copayments, deductibles, or
coinsurance obligations of Cigna insureds. Cigna allegedly
informed plaintiff that in order to receive payment for any
future medical services rendered to a Cigna insured, the
insured would have to pay his or her cost share obligation
prior to Cigna processing or paying a claim submitted by
alleges that since the August 2015 letter, Cigna has
repeatedly refused to provide to plaintiff requested
documentation or to process valid claims for payment for
plaintiffs services to Cigna insureds. Cigna informed
plaintiff that, in order to have any claim processed, the
Cigna insured would now be required to pay plaintiff up front
for the entire cost of service prior to plaintiff submitting
a claim; plaintiff further alleges that this representation
was false as Cigna has failed to process a valid claim for
services rendered to a Cigna insured after full-prepayment by
the insured. Plaintiff alleges that, as of the date of the
complaint, Cigna has improperly or unlawfully withheld a
total of at least $2, 467, 490.34 for services rendered by
plaintiff to Cigna insureds. Plaintiff further alleges that
Cigna has failed to provide plaintiff with a full and fair
review of adverse benefit determinations.
filed this action to address defendants' repeated and
deliberate failure to process and make payments to plaintiff
on claims for services rendered to Cigna insureds. Plaintiff
brings the following claims under ERISA: a claim under §
502(a)(1)(B) for benefits due, a claim for failure to comply
with federal claims regulations under 29 U.S.C. § 1132,
a claim for failure to provide plan and claims documentation
under 29 U.S.C. § 1132(c)(1), a claim for declaratory
and injunctive relief, and a claim for attorneys' fees.
Plaintiff has further alleged state law claims under North
Carolina law for breach of contract, unjust enrichment,
unfair and deceptive trade practices.
have moved to dismiss plaintiffs complaint under Rule
12(b)(6) of the Federal Rules of Civil Procedure. Defendants
argue that plaintiff lacks standing to bring its ERISA
claims; has failed to state a plausible claim for relief
under ERISA because it has not identified any services
rendered to Cigna members, not linked any members to any
specific employee benefit plan, nor alleged any facts which
support that any of the plans covered any of the services at
issue; and that plaintiff has failed to exhaust its
administrative remedies. Defendants further contend that
plaintiff has failed to state a claim under North Carolina
of the Federal Rules of Civil Procedure "requires only a
short and plain statement of the claim showing that the
pleader is entitled to relief and which provides "the
defendant fair notice of what the claim is and the grounds
upon which it rests." Erickson v. Pardus, 551
U.S. 89, 93 (2007) (internal quotations, alterations, and
citations omitted). A Rule 12(b)(6) motion tests the legal
sufficiency of the complaint. Papasan v. Allain, 478
U.S. 265, 283 (1986). When acting on a motion to dismiss
under Rule 12(b)(6), "the court should accept as true
all well-pleaded allegations and should view the complaint in
a light most favorable to the plaintiff." Mylan
Labs., Inc. v. Matkari, 7 F.3d 1130, 1134 (4th
Cir.1993). A complaint must allege enough facts to state a
claim for relief that is facially plausible. Bell
Atlantic Corp. v. Twombly, 550 U.S. 544, 570 (2007).
Facial plausibility means that the facts pled "allow
the court to draw the reasonable inference that the defendant
is liable for the misconduct alleged, " and mere
recitals of the elements of a cause of action supported by
conclusory statements do not suffice. Ashcroft v.
Iqbal, 556 U.S. 662, 678 (2009). A complaint must be
dismissed if the factual allegations do not nudge the
plaintiffs claims "across the line from conceivable to
plausible." Twombly, 550 U.S. at 570.
comprehensively regulates, among other things, employee
welfare benefit plans that, 'through the purchase of
insurance or otherwise, ' provide medical, surgical, or
hospital care, or benefits in the event of sickness,
accident, disability, or death." Pilot Life Ins. Co.
v. Dedeaux, 481 U.S. 41, 44 (1987) (quoting 29 U.S.C.
§ 1002(1)). The policy behind ERISA's enactment was
to "induc[e] employers to offer benefits by assuring a
predictable set of liabilities, under uniform standards of
primary conduct and a uniform regime of ultimate remedial
orders and awards when a violation has occurred."
Rush Prudential HMO, Inc. v. Moran, 536 U.S. 355,
379 (2002). To this end, only plan participants,
beneficiaries, and fiduciaries are granted a private cause of
action under ERISA. Franchise Tax Bd. of State of Cal. v.
Constr. Laborers Vacation Tr. for S. California, 463
U.S. 1, 27 (1983); see also Rojas v. Cigna Health &
Life Ins. Co., 793 F.3d 253, 256 (2d Cir. 2015).
beneficiary is defined by ERISA as a person designated by a
participant or the terms of the employee benefit plan who is
or may become entitled to a benefit under the plan. 29 U.S.C.
§ 1002(8). "'Beneficiary, ' as it is used
in ERISA, does not without more encompass healthcare
providers." Rojas, 793 F.3d at 257; see
also Hobbs v. Blue Cross Blue Shield of Alabama, 276
F.3d 1236, 1241 (11th Cir. 2001) (healthcare providers
generally not considered beneficiaries or participants for
purposes of ERISA). Accordingly, plaintiff, a healthcare
provider, may not directly file suit against defendants under
ERISA as a beneficiary. Spinedex Physical Therapy USA
Inc. v. United ...