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Sanctuary Surgical Centre, Inc., et al v. Connecticut General Life Insurance Co.

January 5, 2012

SANCTUARY SURGICAL CENTRE, INC., ET AL., PLAINTIFFS,
v.
CONNECTICUT GENERAL LIFE INSURANCE CO., INC., ET AL., DEFENDANTS.



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

ORDER GRANTING DEFENDANT'S MOTION TO DISMISS

THIS CAUSE is before the Court upon Defendant's Motion to Dismiss [DE # 12]. For the reasons to follow, the Court will grant Defendant's motion and dismiss Plaintiffs' Complaint without prejudice.

I.

The essential facts of this case have previously been set forth in Sanctuary Surgical Centre, Inc. v. United Healthcare, Inc., No. 10-cv-81589-DTKH, 2011 WL 2134534 (S.D. Fla. May 27, 2011). 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 Defendants, Connecticut General Life Insurance Company, Inc., CIGNA Healthcare, Inc., and CIGNA Healthcare of Florida, Inc. (collectively "CIGNA") are the insurers providing and administering coverage under the plans. Plaintiffs performed a procedure known as "manipulation under anesthesia ("MUA") on approximately 332 patients with CIGNA policies after having received pre-authorization from Defendants. Although Defendants had previously provided coverage for MUAs by sending payment directly to Plaintiffs or the patients, Defendants 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 Sanctuary Surgical Centre, Inc. v. United Healthcare, Inc., in the instant case Plaintiffs advance four causes of action:

* wrongful denial of benefits under § 502(a)(1)(B)*fn3 of ERISA;

* breach of the fiduciary duty of loyalty under § 502(a)(3) of ERISA;

* failure to provide full and fair review pursuant to 29 U.S.C. § 1133; and

* equitable estoppel under the federal common law of § 502(a)(1)(B) of ERISA. Plaintiffs originally asserted these claims against Defendants and others in Sanctuary Surgical Centre, Inc. v. United Healthcare, Inc., but the Court granted Defendants' motion to sever, and Plaintiff thus re-filed this claim separately against only the CIGNA defendants. Id. When granting Defendants' motion to sever, the Court also granted motions to dismiss in light of pleading deficiencies relating to Plaintiffs' failure to cite specific plan terms and provisions. Id. In the instant case, Defendants reassert this basis for dismissal and add other arguments that will be discussed and analyzed below.

II.

This Court possesses federal subject-matter jurisdiction under 28 U.S.C. § 1331 because Plaintiffs' claims arise under ERISA, 29 U.S.C. § 1001 et seq. Venue is proper in this district pursuant to 28 U.S.C. § 1391(b)(2) because a substantial part of the events giving rise to the claims occurred in the Southern District of Florida.

III.

Granting a motion to dismiss is appropriate when a complaint contains simply "a formulaic recitation of the elements of a cause of action." See Bell Atlantic Corp. v. Twombly, 550 U.S. 544 (2007). To survive a motion to dismiss, a complaint must contain factual allegations that "raise a reasonable expectation that discovery will reveal evidence" in support of the claim and that plausibly suggest relief is appropriate. Id. On a motion to dismiss, the complaint is construed in the light most favorable to the non-moving party, and all facts alleged by the non-moving party are accepted as true. See Hishon v. King & Spalding, 467 U.S. 69, 73 (1984); Wright v. Newsome, 795 F.2d 964, 967 (11th Cir. 1986). Mere conclusory allegations, however, are not entitled to be assumed as true upon a motion to dismiss. See Ashcroft v. Iqbal, 129 S.Ct. 1937, 1951 (2009). The threshold is "exceedingly low" for a complaint to survive a motion to dismiss for failure to state a claim upon which relief can be granted. See Ancata v. ...


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