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MSPA Claim I, LLC v. National Fire Insurance Company of Hartford

United States District Court, S.D. Florida, Miami Division

September 20, 2017

MSPA CLAIM I, LLC, a Florida limited liability company, as assignee of Florida Healthcare Plus, on behalf of itself and all other similarly situated Medicare Advantage Organizations in the State of Florida, Plaintiff,
v.
NATIONAL FIRE INSURANCE COMPANY OF HARTFORD, Defendant.

          ORDER GRANTING MOTION TO DISMISS

          FEDERICO K. MORENO, UNITED STATES DISTRICT JUDGE

         This case stems from the Medicare Secondary Payer Act's private right of action, which allows Plaintiff, an assignee of a Medicare Advantage Organization, to sue for reimbursement of Medicare benefits provided to its enrollee, who suffered burns at a location insured by Defendant National Fire Insurance Company of Hartford. Defendant moved to dismiss arguing the statutory threshold amount is not met. This Court agrees the threshold amount is a prerequisite to filing suit under the Act's private right of action. Accordingly, the Court grants the motion to dismiss.

         THIS CAUSE came before the Court upon Defendant's Motion to Dismiss (D.E. 46), I filed on February 6. 2017.

         THE COURT has considered the motion, the response, pertinent portions of the record, I and being otherwise fully advised in the premises, it is

         ADJUDGED that the motion is GRANTED. It is also

         ADJUDGED that all other pending motions are DENIED as moot.

         I. Background

         Plaintiff MSPA Claims I, LLC invokes the private cause of action provision of the Medicare Secondary Payer Act to recover reimbursement of Medicare benefits in this case. Plaintiff is a twice-removed assignee of a Medicare Advantage Organization, called Florida Healthcare Plus, Inc., which paid medical bills incurred by its enrollee named L.H., who suffered burns at a Sonic location. Plaintiff alleges Defendant National Fire Insurance Company provided liability insurance for Sonic and should reimburse the costs incurred by Florida Healthcare Plus, Inc. Plaintiff also alleges that National Fire settled L.H.'s claim against Sonic for $1, 500 on June 4, 2014, but National Fire failed to reimburse Florida Healthcare Plus, Inc. for that amount.

         Florida Healthcare Plus, Inc. originally assigned its claim against National Fire to La Ley Recovery Systems, Inc., which, in turn, assigned its claim to Plaintiff MSPA Claims I, LLC.

         The Second Amended Complaint asserts two counts against National Fire. The first is a private right of action under the Medicare Secondary Payer Act, 42 U.S.C. § 1395y(b)(3)(A), seeking double damages for National Fire's alleged failure to reimburse Florida Healthcare Plus for Medicare benefits it advanced to cover L.H.'s medical costs. The second count is for a declaratory judgment as to National Fire's obligation to reimburse the payment of conditional Medicare benefits.

         Defendant National Fire is moving to dismiss arguing the settlement amount of $1, 500 is I less than the threshold amount necessary to trigger National Fire's reimbursement obligation under the Medicare Secondary Payer Act. Second, Defendant National Fire argues the assignment to Plaintiff is invalid because the Medicare Advantage Organization, Florida Healthcare Plus, Inc. did not approve it prior to the filing of the complaint.

         II. Legal Standard

         "To survive a motion to dismiss, plaintiffs must do more than merely state legal conclusions, " instead plaintiffs must "allege some specific factual basis for those conclusions or face dismissal of their claims." Jackson v. BellSouth Telecomm., 372 F.3d 1250, 1263 (11th Cir. 2004). When ruling on a motion to dismiss, a court must view the complaint in the light most favorable to the plaintiff and accept the plaintiffs well-pleaded facts as true. See St. Joseph's Hosp., Inc. v. Hosp. Corp. of Am., 795 F.2d 948, 953 (11th Cir. 1986). This tenet, however, does not apply to legal conclusions. See Ashcroft v. Iqbal, 129 S.Ct. 1937, 1949 (2009). Moreover, "[w]hile legal conclusions can provide the framework of a complaint, they must be supported by factual allegations." Id. at 1950. Those "[f]actual allegations must be enough to raise a right to relief above the speculative level on the assumption that all of the complaint's allegations are true." Bell Ail. Corp. v. Twombly, 550 U.S. 544, 545 (2007). In short, the complaint must not merely allege a misconduct, but must demonstrate that the pleader is entitled to relief. See Iqbal, 129 S.Ct. at 1950.

         III. ...


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