Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

GVB MD, LLC v. Blue Cross and Blue Shield of Florida, Inc.

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

November 12, 2019

GVB MD, LLC d/b/a MIAMI BACK AND NECK SPECIALISTS, Plaintiff,
v.
BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC. d/b/a FLORIDA BLUE, Defendant.

          ORDER GRANTING MOTION TO DISMISS AND CLOSING CASE

          FEDERICO A. MORENO UNITED STATES DISTRICT JUDGE.

         THIS CAUSE came before the Court upon Defendant's Motion to Dismiss Plaintiffs Amended Complaint for Failure to State a Claim. The Court has considered the motion, the response in opposition, the reply, the pertinent portions of the record, and being otherwise fully advised in the premises, it is ADJUDGED that the motion to dismiss the amended complaint is GRANTED, and the case is DISMISSED WITH PREJUDICE due to Plaintiffs lack of standing.

         I. BACKGROUND

         This case essentially deals with a contract dispute arising under the Employee Retirement Income Security Act of 1974 ("ERISA") § 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B). Plaintiff Miami Back and Neck Specialists, "a medical practice that performs spine surgery and other related treatments on its patients in licensed health care facilities throughout the State of Florida," brings forth two claims for breach of contract and declaratory judgment against Defendant Blue Cross and Blue Shield of Florida related to an alleged denial of insurance benefits arising under an ERISA plan. Plaintiff avers in its amended complaint that on various dates, its doctors performed spine surgery and related services on three patients, whose initials are A.S., A.V., and A.P., and that Defendant has failed to pay, or has woefully underpaid, "for the covered services in an amount equal to the provider's billed charges, or the usual, customary, and reasonable rate for the services provided, less the Patient Responsibility under the terms of the applicable Plan."

         Plaintiff is "a non-participating, out-of-network provider" that does not have an express contract with the Defendant. Nevertheless, it proceeds on its causes of action alleging that the three patients it treated assigned their benefits from their ERISA plans to the Plaintiff. "As part of the intake and admissions process at Miami Back, the Members [i.e., patients] execute[d] written assignment of benefits, assigning their rights to receive health benefits under any applicable Plans to Miami Back." Plaintiff notes that before initiating suit, it filed internal appeals with Defendant seeking reconsideration of its claims, and that "Defendant failed to respond to the internal appeals in any meaningful way."[1] Now, "[a]s Assignee of the Plans, Plaintiff is entitled to recover benefits due to the Members and enforce the rights of the Members under the terms of the Plans."

         In response, Defendant filed a motion to dismiss, arguing, among other things, that Plaintiff lacks standing to sue because the assignments of benefits were invalid. Defendant attached to its motion each of the three insureds' health benefits plans, and pointed to anti-assignment language in each. All three plans similarly state that "[e]xcept as set forth the in 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." Plaintiff contests dismissal by arguing that Defendant, through its prior course of dealings, waived or is estopped from relying on the anti-assignment provisions. Prior to litigation, Plaintiff claims that the Defendant failed to ever raise the issue of the anti-assignment provisions during the internal appeals process, and that the Defendant all but recognized the assignments when it made direct payments under the plans to Plaintiff instead of the insureds.

         The Court now evaluates the motion to dismiss.

         II. LEGAL STANDARD

         To survive a motion to dismiss under Federal Rule of Civil Procedure 12(b)(6), a complaint must plead sufficient facts to state a claim for relief that is plausible on its face. Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009); Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570 (2007). To establish a facially plausible case, a plaintiff must show "more than a sheer possibility that a defendant has acted unlawfully." Iqbal, 556 U.S. at 678. In considering a Rule 12(b)(6) motion, the Court construes the complaint in a light most favorable to the non-movant and accepts all allegations of facts as true. Twombly, 550 U.S. at 555-56. Plaintiff need not provide "detailed factual allegations," but the "obligation to provide the 'grounds' of his 'entitle[ment] to relief requires more than labels and conclusions, and a formulaic recitation of the elements of a cause of action will not do." Id. at 555. "Threadbare recitals of the elements of a cause of action, supported by mere conclusory statements, do not suffice." Iqbal, 556 U.S. at 678.

         III. ANALYSIS

         A. Plaintiff Lacks Standing to Sue Pursuant to the Anti-Assignment Provisions

         Upon review of the record, the Court agrees that for the reasons cited in the motion to dismiss, Plaintiff lacks standing to sue under the unambiguous terms of the insureds' health plans.

         As the Eleventh Circuit Court of Appeals recently reaffirmed, "[t]o maintain an action under ERISA, a plaintiff must have standing to sue under the statute, which is not jurisdictional, Article III standing, but a right to make a claim under the statute." Griffin v. Coca-Cola Enters., Inc., 686 Fed.Appx. 820, 821 (11th Cir. 2017) (citing Physicians Multispecialty Grp. v. Health Care Plan of Horton Homes, Inc., 371 F.3d 1291, 1293-94 (11th Cir. 2004)). Pursuant to ERISA § 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B), generally two categories of persons have a right to make a claim under an ERISA plan: plan beneficiaries and plan participants.[2] Healthcare providers, like the Plaintiff, are typically not plan beneficiaries or participants, and thus lack independent standing to sue. See Coca-Cola Enters., 686 Fed.Appx. at 821; Physicians Multispecialty Grp., 371 F.3d at 1294. The Eleventh Circuit recognizes, however, that healthcare providers may contractually obtain derivative standing through a written assignment of benefits by a plan beneficiary or participant. Coca-Cola Enters., 686 Fed.Appx. at 821-22; Physicians Multispecialty Grp., 371 F.3d at 1294.

         But the Eleventh Circuit also recognizes, fatal to the Plaintiffs claims, that "an unambiguous anti-assignment provision in an ERISA-governed welfare benefit plan is valid and enforceable, and will operate to void the assignment. If there is such an unambiguous anti-assignment provision, the healthcare provider will lack derivative standing and cannot maintain the ERISA action." Coca-Cola Enters., 686 Fed.Appx. at 821-22. Just as Defendant argues, there is a clear anti-assignment provision in each of the three patients' health plans. The provisions similarly state, in no uncertain terms, that "[e]xcept as set forth the in 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 ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.