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Surgery Center of Viera, LLC v. Southeastern Surveying and Mapping Corp.

United States District Court, M.D. Florida, Orlando Division

January 31, 2018

SURGERY CENTER OF VIERA, LLC, Plaintiff,
v.
SOUTHEASTERN SURVEYING AND MAPPING CORPORATION, BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC., JAMES PETERSEN and SOUTHEASTERN SURVEYING AND MAPPING WELFARE PLAN, Defendants.

          REPORT AND RECOMMENDATION

          THOMAS B. SMITH UNITED STATES MAGISTRATE JUDGE

         Pending before the Court is Defendants' Motion to Dismiss Amended Complaint. (Doc 28). I have read the parties' motion papers and held a January 24, 2018 hearing where counsel argued their positions. Now, after due consideration, I respectfully recommend that the motion be granted, and that Plaintiff's complaint be dismissed with prejudice.

         I. Background

         Plaintiff Surgery Center of Viera, LLC provided medical services to KR in return for an assignment (“Assignment”) of his benefits under the Southeastern Surveying and Mapping Welfare Plan (“Plan”) (Doc. 20, ¶¶ 28-31). The Assignment includes all of KR's “medical and other health care benefits, insurance payments and any other payment or reimbursement for health care services rendered to” KR by Plaintiff “regardless of its managed care network participation or contract status.” (Doc. 20 at 12). KR also assigned to Plaintiff “[t]o the full extent permitted by law, including without limitation 29 U.S.C. sections 1132(a)(1) and 1132(a)(3) … any legal, administrative or contractual claim pursuant to any group health plan, benefit plan, health care insurance or third party liability insurance concerning medical expenses incurred as a result of the health care services” KR received from Plaintiff (Id.). The Assignment includes “any ERISA breach of fiduciary duty claim and any other statutory, regulatory, administrative or other legal claim.” (Id.).

         The Plan is self-insured by Defendant Southeastern Surveying and Mapping Corporation[1] (Id., ¶ 6). Defendant James Petersen is the Plan Administrator, and Defendant Blue Cross and Blue Shield of Florida, Inc. provides administrative services to the Plan (Id., ¶¶ 7, 9). Plaintiff is an “out-of-network” provider of services to members of the Plan (Id., ¶ 26). This means Plaintiff is not contractually bound to accept a negotiated rate or fee for the services it furnishes to Plan beneficiaries (Id., ¶¶ 21, 26).

         Plaintiff billed Blue Cross $286, 112 for services rendered to KR (Id., ¶ 32). Blue Cross paid Plaintiff $37, 799.91 for those services (Id., ¶ 34). Plaintiff appealed to Blue Cross, on three occasions, the denial of the balance of its billing (Id., ¶¶ 35-37). Those appeals were not successful, [2] and Plaintiff filed this lawsuit under the Employee Retirement Income Security Act of 1974 (“ERISA”) (Id.). Count I of Plaintiff's amended complaint alleges that Defendants breached the terms of the Plan by paying Plaintiff less than the full amount of its bill without providing valid evidence or information to support the payment decision in violation of § 502(a) of ERISA (Id., ¶¶ 50-59). Count II alleges that 29 U.S.C. § 1132(a)(3) imposes on Defendants fiduciary duties of loyalty and care toward Plaintiff (Id., ¶¶ 60-66). Defendants allegedly breached these duties by arbitrarily and capriciously failing to pay Plaintiff the amount it is owed for the treatment provided to KR (Id.). Count III asserts that Defendants Southeastern, Petersen and the Plan failed to furnish copies of the Plan documents to Plaintiff in violation of 29 U.S.C. § 1132(c)(1)(B) (Id., ¶¶ 67-69).

         The Plan contains the following anti-assignment clause:

Assignment of Benefits to Providers .
Except as set forth in the last paragraph of this section, we will not honor any of the following assignments, or attempted assignments, by you to any Provider:
• An assignment of the benefits due to you for Covered Services under this Benefit Booklet;
• An assignment of your right to receive payments for Covered Services under this Benefit Booklet; or.
• an assignment of a claim for damage resulting from a breach, or an alleged breach, of the Group Master Policy.
We specifically reserve the right to honor an assignment of benefits or payment by you to a Provider who: 1) is In-Network under your plan of coverage; 2) is a NetworkBlue Provider even if that Provider is not in the panel for your plan of coverage; 3) is a Traditional Program Provider; 4) is a ® BlueCard (Out-of-State) PPO Program Provider; or 5) is a ® BlueCard (Out-of-State) Traditional Program Provider.

(Doc. 28-2 at 36). Defendants seek dismissal of the amended complaint on the grounds that: (1) by virtue of the anti-assignment clause, Plaintiff lacks standing to assert its claims; (2) Plaintiff has failed to allege that it has exhausted its administrative remedies; (3) Plaintiff has not alleged that Defendants breached a specific provision of the Plan; (4) Count I seeks legal damages on a claim for which Congress has only authorized equitable remedies; (5) Count I against Southeastern, Petersen and the Plan should be dismissed because the Plan delegates all authority to Blue Cross; (6) Plaintiff is barred from asserting Count II because it seeks the same relief in Count I; (7) Count II fails to plead with sufficient particularity, a claim for equitable relief; (8) Count II seeks legal relief on a claim for which Congress has only authorized equitable remedies; (9) the exhibits to the amended complaint contradict ...


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