Taylor Theunissen, M.D, LLC v. United Healthcare Group, Inc.

          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 ...