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Sanctuary Surgical Centre, Inc., et al v. Unitedhealthcare

December 30, 2011


The opinion of the court was delivered by: Daniel T. K. Hurley United States District Judge


THIS CAUSE is before the Court upon Defendant's Motion to Dismiss [DE # 76]. For the reasons to follow, the Court will grant Defendant's motion and dismiss Plaintiffs' Amended Complaint without prejudice.


The facts underlying this case as set forth in a prior version of the Amended Complaint were previously summarized in the Order Granting Defendants' Motions to Dismiss Without Prejudice [DE # 65]. The facts relevant to the instant motion are essentially the same. In brief, Plaintiffs are four surgical centers and two medical service providers seeking to recover payment of benefits allegedly due under employer health benefits plans.*fn1 Defendant, UnitedHealthcare, Inc. ("United") is the insurer providing and administering coverage under the plans. Plaintiffs performed a procedure known as "manipulation under anesthesia" ("MUA") for which they received pre-authorization from Defendant. Although Defendant had previously provided coverage for MUAs by sending payment directly to Plaintiffs or the patients, Defendant later denied coverage on the basis that the MUAs were unproven, experimental, investigational, not medically necessary, or otherwise not a covered service under the particular plan at issue*fn2 and therefore not entitled to coverage.

As in the original Complaint, in the Amended Complaint Plaintiffs assert four claims:

* Count One: Violation of § 502(a) of the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1132(a)(1)(B), by failing to provide the coverage benefits owed under the plans.

* Count Two: Violation of § 502(a)(3) of ERISA by breaching the fiduciary duties of care and loyalty under § 3(21)(A), specifically by improperly denying coverage and by granting pre-approvals/pre-authorizations and then denying coverage.

* Count Three: Failure to provide full and fair review in the process of denying coverage to Plaintiffs.

* Count Four: Seeking to equitably estop Defendant from denying coverage after having granted pre-approvals on the basis of an inherent ambiguity in the language of each plan.

The Complaint originally named Defendant and other insurers together as co-defendants. The Court granted a motion to sever, and United is now the only remaining defendant in this action. The Court also granted a prior motion to dismiss. In addition to issues relating to misjoinder of parties, the Court dismissed the complaint for failure to plead with sufficient specificity to pass muster under Federal Rules of Civil Procedure 8 and 10 and for shotgun pleading. Additionally, the Court found deficiencies with respect to individual claims. Regarding count one, wrongful denial of benefits, the Court found that Plaintiffs did not sufficiently allege medical necessity of the MUA for each plaintiff in light of that plaintiff's condition. As to count four, seeking equitable estoppel, the Court found that Plaintiffs did not sufficiently demonstrate an ambiguity in the plan at issue as required by Katz v. Comprehensive Plan of Grp. Ins., 197 F.3d 1084, 1090 (11th Cir. 1999). As to count three asserting a failure to provide full and fair review, the Court found that Plaintiffs could not state a plausible claim for relief without identifying the plans or plan terms with which the claim denials were inconsistent. Finally, as to count two for breach of fiduciary duty, the Court dismissed this claim because it was ultimately premised not on Defendant's alleged misrepresentations but on its denial of benefits and therefore duplicative of count one.

In the instant motion to dismiss, Defendant challenges the Amended Complaint on a variety of grounds, including a reassertion of the bases of the initial dismissal. Defendant argues first that the entire complaint must be dismissed because Plaintiffs have not provided the level of specificity the Court required in its dismissal order [DE # 65]. Specifically, Defendant argues that Plaintiffs' failure to identify the specific ERISA plans that covered each patient and the terms of those plans that Defendant allegedly violated is grounds for dismissal of the entire complaint. Similarly, Defendant argues that Plaintiffs still have not plausibly alleged that Defendant improperly denied benefits for the MUAs because Plaintiffs have not shown medical necessity with respect to the condition of each patient. Furthermore, Defendant argues Plaintiffs have not passed the additional hurdle of showing that Defendant exceeded the discretion reposed in it to interpret and apply plan terms.

Turning to the breach of fiduciary duty claim, Defendant argues that Plaintiffs do not have standing to assert such a claim because, although the patients assigned their plan benefits to Plaintiffs, such an assignment is insufficient under these circumstances to assign the right to sue for a breach of fiduciary duty. In addition, Defendants reassert that the claim is duplicative of the claim for wrongful denial of benefits in count one.

Defendant also reasserts that the full and fair review claim must be dismissed because Plaintiffs have still not identified the specific plans terms that have allegedly been violated, and Defendant adds the argument that the full and fair review claim can be dismissed because it would not actually entitle Plaintiffs to any relief other than allowing them to pursue their claims in federal court, which they are already doing. Finally, Defendant again asserts ...

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