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Aesthetic and Reconstructive Breast Center, LLC v. United Healthcare Group, Inc.

United States District Court, D. Connecticut

March 12, 2019




         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 contacts 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 pre-authorizing the provider to perform the surgeries. Defendants now move to dismiss principally on grounds that the Center has not adequately alleged its state law claims and that the Center's claims are otherwise preempted by the federal Employee Retirement Income Security Act (ERISA). I mostly agree and will grant defendants' motion to dismiss except as to the plaintiff's claim for promissory estoppel.


          The following facts as alleged by the plaintiff in the amended complaint are accepted as true for purposes of ruling on defendants' motion to dismiss. Doc. #7. Plaintiff Aesthetic and Reconstructive Breast Center, LLC, is a medical practice located in Louisiana run by Dr. Alireza Sadeghi, who specializes in reconstructive breast surgery. Dr. Sadeghi performed a medically necessary mastectomy on a patient in March of 2016, and then performed a medically necessary follow-up surgery on the same patient in July of 2016.

         The patient worked for defendant Jacobs Engineering Group Inc., which sponsored her employee health plan. According to the complaint, defendant United Healthcare Group, Inc. (UHG) acted as the claims administrator for the plan.[2]

         The parties do not dispute that the plan is governed by ERISA. The Center was an out-of-network provider under the patient's plan. Doc. #12-1 at 87. Under the terms of the plan, the patient could not assign her benefits under the plan to her medical provider without UHG's consent, Doc. #12-1 at 88, and it is uncontested that the patient did not assign her benefits to the Center. See Doc. #22 at 1-2.

         Although the plan did not require it of an out-of-network provider prior to treating a patient, see Doc. #12-1 at 87, the Center contacted UHG to request prior authorization before each surgery at issue in this case. UHG authorized rendering surgery in each instance. The Center alleges that the authorization created an implied contract by defendants to pay the Center a reasonable amount for the Center's services, and in the alternative, that the authorization was a promise to pay the Center a fair and reasonable rate for its services. After the surgeries, the Center billed defendants for a total of $390, 700, which the Center alleges to be a reasonable rate for the surgical services performed. Defendants paid none of the billed charges.

         The Center has filed this federal diversity lawsuit against defendants alleging the following causes of action: breach of contract (Count 1), promissory estoppel (Count 2), account stated (Count 3), and fraudulent inducement (Count 4). Defendants now move to dismiss. Doc. #11.


         For purposes of a motion to dismiss for failure to state a claim, 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). This “plausibility” requirement is “not akin to a probability requirement, ” but 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 Jacobs

         The amended complaint alleges that Jacobs was the patient's employer but does not allege any actions taken by Jacobs to agree to or induce the Center to perform surgery for the patient. In the absence of any allegations that it was Jacobs who had dealings with the Center or did anything other than employ the patient, I will grant Jacobs' motion to dismiss as to all of the Center's claims against it.[3]

         Claims against UHG

         The Center's amended complaint names “United HealthCare Group, Inc.” as a defendant and the entity that administered the patient's insurance plan. Doc. #7 at 1, 3 (¶ 4). A company identifying itself as “UnitedHealth Group, Inc. s/h/a United Healthcare Group, Inc.” (whom I will assume to be the same as the named defendant, UHG) has filed this motion to dismiss, and it argues that the Center has sued the wrong corporate party, because the actual plan administrator was UHG's corporate subsidiary, UnitedHealthcare Insurance Company. Doc. #12 at 1-2 & n.1, 8, 9; Doc. #12-2 at 2-3 (¶ 4). UHG has filed alongside its motion to dismiss an affidavit attesting to this corporate relationship, as well as a copy of its Jacobs Engineering Group plan. Doc. #12-1; Doc. #12-2.

         The corporate identity and affiliations of UHG are questions of fact, and for purposes of evaluating a motion to dismiss the Court must accept as true for pleading purposes all of plaintiff's allegations subject to any documents that are referenced in or otherwise integral to the complaint. See Goel v. Bunge, Ltd., 820 F.3d 554, 559 (2d Cir. 2016). The Jacobs Engineering Group plan repeatedly refers to any United entity just as “UnitedHealthcare, ” and provides contact information for the claims administrator at a Minnesota address associated with “United Healthcare Services, Inc.” Doc. #12-1 at 133. This entity name is different from the one (“UnitedHealthcare Insurance Company”) that UHG in its briefing claims to be the true administrator of the plan. Doc. #12 at 2 n.1. Therefore, the Court does not have a proper basis to conclude at the pleading stage that the Center has sued the wrong party. Compare Doc. #25-3 at 1 to Taylor Theunissen, M.D., LLC v. United HealthCare Group, Inc., 18cv606 (D. Conn. 2018) (cover of certificate of coverage identifies UnitedHealthcare Insurance Company and names same as offeror and underwriter of coverage).

         Because I must draw factual inferences in the Center's favor at this stage of the proceedings, I therefore will allow the case to proceed at this time against UHG without prejudice to a motion for summary judgment on this basis at a future time. The Court encourages counsel to consult in good faith to determine whether they can simply agree on this issue of the proper defendant to be sued rather than expending the Court's and ...

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