United States District Court, D. Connecticut
ORDER GRANTING IN PART AND DENYING IN PART MOTION TO
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 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.
essentially the question now before me in this
case. 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
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.
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.
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
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.
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.
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
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
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.
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).
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 ...