United States District Court, D. Connecticut
ORDER GRANTING MOTIONS TO DISMISS
JEFFREY ALKER MEYER, UNITED STATES DISTRICT JUDGE
It is a
common practice for doctors and other medical providers to
seek authorization from a patient's insurance company
before agreeing to provide expensive medical care. As often
as not, the provider calls the insurance company and receives
what it understands to be a pre-authorization. But sometimes
the insurance company ends up deciding not to pay for what
the provider thought was pre-authorized. So the question
becomes whether the medical provider may recover in court
against the insurance company.
That's
essentially the question now before me in this
case.[1] The plaintiff is a medical provider who
alleges that defendants failed to pay for surgeries despite
issuing a written pre-authorization to perform the surgeries.
Defendants now move to dismiss on grounds that the
pre-authorizations are not enforceable. I agree on the facts
of the present record and will therefore dismiss the
complaint.
Background
The
following facts as alleged by the plaintiff are accepted as
true for purposes of ruling on defendants' motions to
dismiss. The plaintiff-Taylor Theunissen, M.D., LLC-is a
limited liability company based in Louisiana. Dr. Theunissen
performed medically necessary breast surgery on a patient in
August 2016 and then again in November 2016. The patient was
an employee of defendant Cheniere Energy Inc. (Cheniere), a
company based in Texas. The patient was covered under an
employer-sponsored health care plan that was allegedly
administered by defendant United Healthcare Group, Inc. (UHG)
which is based in Connecticut.[2] The plan and certificate of
coverage are part of the record in this case. Docs. #25-2 and
#25-3.
According
to Theunissen, before performing both surgeries, Theunissen
contacted UHG and allegedly received written
pre-authorizations to perform the surgery. Theunissen billed
UHG a total of $257, 000 for both surgeries but UHG only paid
$2, 392.38.
Theunissen
was an out-of-network provider. According to Theunissen,
however, UHG was aware that Theunissen was an out-of-network
provider but never disclosed that it did not intend to pay
for Theunissen's services at the time of authorization.
Instead, UHG allegedly induced Theunissen to provide the
surgery services while knowing that it would deny full
payment.
Following
oral argument on the pending motions, I requested that the
parties submit the alleged written pre-authorizations, and
they have done so. Doc. #48-1. These two documents take the
form of letters addressed to the patient from United
HealthCare Services, Inc., on behalf of UnitedHealthcare
Insurance Company, with a “cc” copy to
Theunissen. Id. at 1, 3. They list anticipated
outpatient surgery procedures by specific billing code and
then state in relevant part that “[b]ased on the
information submitted to us for review and your current
health benefit plan, we found that the health care service(s)
below are eligible for Outpatient Facility coverage.”
Id. at 1, 3. The letters go on to state that
“[p]ayment is based on information in the submitted
claim, the actual health care services you received, and your
plan benefit language and eligibility when the services are
provided.” Id. at 1, 4. The letters further
state that “[t]he information in this letter does not
guarantee payment or represent a treatment decision, ”
and that “[t]his approval does not guarantee that the
plan will pay for the service(s).” Ibid.
Theunissen
has filed this federal diversity lawsuit against UHG and
Cheniere alleging the following state law causes of action:
breach of contract (Count 1), promissory estoppel (Count 2),
account stated (Count 3), and fraudulent inducement (Count
4). Theunissen also alleges federal causes of action under
the Employee Retirement Income Security Act of 1974 (ERISA),
including failure to make payments as required by federal
ERISA law (Count 5), breach of fiduciary duty under ERISA
(Count 6), failure to establish and maintain reasonable
claims procedures as required by ERISA (Count 7), and failure
to establish a summary plan description as required under
ERISA (Count 8). Defendants UHG and Cheniere move to dismiss.
Docs. #18, #24, #41.
Discussion
The
Court must accept as true all factual matters alleged in a
complaint, although a complaint may not survive unless the
facts it recites are enough to state plausible grounds for
relief. See, e.g., Ashcroft v. Iqbal, 556
U.S. 662, 678 (2009); Mastafa v. Chevron Corp., 770
F.3d 170, 177 (2d Cir. 2014). Although this
“plausibility” requirement is “not akin to
a probability requirement, ” it “asks for more
than a sheer possibility that a defendant has acted
unlawfully.” Iqbal, 556 U.S. at 678. Because
the focus must be on what facts a complaint alleges, a court
is “not bound to accept as true a legal conclusion
couched as a factual allegation” or “to accept as
true allegations that are wholly conclusory.” Krys
v. Pigott, 749 F.3d 117, 128 (2d Cir. 2014). In short,
my role in reviewing a motion to dismiss under Rule 12(b)(6)
is to determine if the complaint-apart from any of its
conclusory allegations-alleges enough facts to state a
plausible claim for relief.
Claims
against Cheniere
The
amended complaint alleges that Cheniere was the patient's
employer but does not allege actions taken by Cheniere to
agree to or induce Theunissen to perform surgery for the
patient. In the absence of any allegations that Cheniere had
any dealings with Theunissen, I will grant Cheniere's
motion to dismiss as to all of Theunissen's state law
claims.
As to
the ERISA claims, however, the plan document as submitted by
defendants reflects that Cheniere was not only the employer
but also the plan sponsor and the plan administrator and that
benefits under the plan were provided under a group insurance
contract between Cheniere and United with United as a
co-administrator. Doc. #25-3 at 184 (designating Cheniere as
“Plan Sponsor” and “Plan
Administrator” and further providing that “[y]our
employer and UnitedHealthcare share responsibility for
administering the plan”). Accordingly, because Cheniere
is ...