Sasson Plastic Surgery, LLC v. UnitedHealthcare of N.Y., Inc.
| Decision Date | 31 March 2021 |
| Docket Number | 17-cv-1674 (SJF) (ARL) |
| Parties | SASSON PLASTIC SURGERY, LLC, Plaintiff, v. UNITEDHEALTHCARE OF NEW YORK, INC., Defendant. |
| Court | U.S. District Court — Eastern District of New York |
Plaintiff Sasson Plastic Surgery, LLC ("Plaintiff" or "Sasson") commenced this action against UnitedHealthcare of New York, Inc. ("Defendant" or "United") asserting violations of the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. §1001 et seq. and state law. Currently before the Court is Defendant's motion to dismiss the amended complaint pursuant to Rule 12(b)(6) of the Federal Rules of Civil Procedure for failure to state a claim. See Docket Entry ("DE") [31]. Plaintiff has opposed the motion. For the reasons set forth herein, the motion is granted in part and denied in part.
The following facts are taken from the amended complaint ("AC"), DE [15], and are assumed to be true for purposes of this motion. In addition to the allegations in the amended complaint itself, that document is also "deemed to include any written instrument attached to it as an exhibit, materials incorporated in it by reference, and documents that, although not incorporated by reference, are 'integral' to the complaint." Sira v. Morton, 380 F.3d 57, 67 (2d Cir. 2004) (citations omitted) (quoting Chambers v. Time Warner, Inc., 282 F.3d 147, 153 (2d Cir. 2002)).
Plaintiff is a New York corporation consisting of a single member, Dr. Homayoun N. Sasson ("Dr. Sasson"), a hand plastic and reconstructive surgeon licensed to practice medicine in New York. AC ¶1. United is an insurance corporation authorized to do business in New York. Id. ¶2. Plaintiff seeks to recover monies from United for medical services it provided to approximately four hundred forty (440) patients covered by healthcare plans issued or administered by United.
Plaintiff does not have an in-network contract with United and therefore is considered an out-of-network or non-participating provider. AC ¶3. As such, Plaintiff "may collect its full charges directly from the patients at the time of service and is not required to accept reduced rates for medical procedures it performs." Id. Alternatively, and as it did in this case, Plaintiff may accept assignment of the patient's benefits in consideration of the health care services provided, and submit its claims for services rendered on behalf of that patient directly to the health plan "to receive from that health plan whatever member benefits that patient is entitled to receive under the patient's health plan." Id.
Plaintiff typically responds to hospital calls to attend to patients requiring emergency treatment, and provides this care without regard to the patient's financial circumstances and regardless of whether there is healthcare insurance. AC ¶4. It does not usually learn whether the patient has healthcare insurance or the identity of the insurance plan until after the patient has been treated and is in stable condition. Id. Either through the patient's admission to the hospital or in follow-up office visits, Plaintiff obtains an assignment of benefits from the patient that permits Plaintiff to send claim forms to the insurance company and authorizes the insurer toremit the patient's benefits directly to Plaintiff. Id. ¶5. Plaintiff alleges that for each claim in this case, it received an assignment of the patient's member benefits under that patient's health plan, "which assignment authorized Plaintiff to send to Defendant claim forms for its charges for the medical care provided to the patient-member and authorized the Defendant to remit those patient-member's related health benefits directly to Plaintiff." Id. The amended complaint does not include any direct quotations from the purported assignments, nor does it attach any such documents.
During the time period from August 1, 2012 through April 2, 2016, Plaintiff provided emergency health care services to patients who were covered under healthcare plans issued or administered by Defendant. AC ¶6. The amended complaint, while silent as to the number of patient or claims at issue, references a list of patient names with claims information that was purportedly provided to Defendant but was not attached for filing "due to HIPAA restrictions." AC ¶8. The Court requested and received a copy of Plaintiff's list, which is in spreadsheet form without numbered lines. By the Court's count, the list sets forth five hundred forty-eight (548) claims made by a total of four hundred forty (440) patient/members.1 Plaintiff claims that the reasonable charges for the services rendered to these patients totaled "not less than $3,886,846.05." Id. ¶7. While it has received some payments from Defendant, Plaintiff claims it is still owed in excess of $2.1 million.2
On May 4, 2016, a tolling agreement was entered into which, according to the amended complaint, "tolled the statute of limitation and any policy limitation 'with regard to [Plaintiff]'s claims against [Defendant] arising out of the nonpayment or underpayment for services provided by [Plaintiff] to beneficiaries of [Defendant]'s health plans.'" AC ¶9 (alterations in original).
Defendant issued Explanation of Benefits forms to patients, or "otherwise communicated with patients and/or other third parties about Plaintiff's claims." AC ¶110. In these communications, Defendant "alleged that Dr. Sasson misrepresented the services that he provided, altered documents, replaced the attending emergency room physicians' names with his name on hospital admissions sheets, or committed other fraud." Id. The amended complaint includes some specifics on of these communications involving fifty-two (52) "John Doe" patients. See id. ¶¶ 111-160. Plaintiff claims to have committed "no fraud or other misrepresentation with respect to its services of its patients or to the related billing" and that any investigation for fraud or irregular billing "lacked any basis in fact and is a sham to support Defendant's improper efforts to avoid paying Plaintiff." Id. ¶164. Plaintiff alleges that Defendant's communications constitute, inter alia, defamation per se and trade defamation. Id. ¶¶168-172.
Plaintiff commenced this action by the filing of a summons and complaint in New York Supreme Court, Nassau County, on February 24, 2017. The case was timely removed to this Court, and Defendant served its initial motion to dismiss on or about June 2, 2017. See DE [12]. Plaintiff acknowledged receipt of the motion, expressed its intent to amend the complaint, andsought an extension of time in which to do so. See DE [14]. The amended complaint was filed on July 7, 2017 and asserts eleven (11) causes of action ("C/A"). There are two federal law causes of action: failure to abide by terms of a Plan in violation of ERISA, §502(a)(1)(B) (First C/A); and breach of fiduciary duty in violation of ERISA, §502(a)(3) (Second C/A). The remaining causes of action arise under state law: breach of Plaintiff's contract with Defendant (Third C/A); breach of patient contracts with Defendant (Fourth C/A); third party beneficiary breach of contract (Fifth C/A); unjust enrichment (Sixth C/A); quantum meruit (Seventh C/A); account stated (Eighth C/A); conversion (Ninth C/A); defamation (Tenth C/A); and tortious interference with contract (Eleventh C/A).
United has moved to dismiss the amended complaint. Plaintiff opposes the motion in part, expressly stating in its opposition that it does not contest the motion to dismiss its Fifth, Eighth, and Ninth Causes of Action. See Plaintiff's Memorandum of Law in Opposition ("Pl. Opp."), at 18 n.10, DE [41].
Defendant seeks dismissal of the action pursuant to Rule 12(b)(6) for failure to state a claim upon which relief can be granted. The standards for analyzing a motion to dismiss are well-established. The court must accept the factual allegations in the complaints as true and draw all reasonable inferences in favor of the plaintiff. Lundy v. Catholic Health Sys. of Long Island Inc., 711 F.3d 106, 113 (2d Cir. 2013) (citations omitted). The court determines "whether the 'well-pleaded factual allegations,' assumed to be true, 'plausibly give rise to an entitlement to relief.'" Hayden v. Paterson, 594 F.3d 150, 161 (2d Cir. 2010) (quoting Ashcroft v. Iqbal, 556 U.S. 662, 679, 129 S. Ct. 1937, 173 L. Ed. 2d 868 (2009)). Iqbal, 556 U.S at 678 (citing Bell Atlantic Corp. v. Twombly, 550 U.S. 544, 556, 127 S. Ct. 1955, 167 L. Ed. 2d 929 (2007)).
The determination of "whether a complaint states a plausible claim for relief" is a "context-specific task that requires the reviewing court to draw on its judicial experience and common sense." Iqbal, 556 U.S at 679. A pleading that does nothing more than recite bare legal conclusions, however, is insufficient to "unlock the doors of discovery." Iqbal, 556 U.S. at 678-679; see also Twombly, 550 U.S. at 555 ). While Rule 8 does not require "detailed factual allegations," it does require more than an "unadorned, the-defendant-unlawfully-harmed-me accusation." Id. at 678 (citing Twombly, 550 U.S. at 555).
In deciding a motion to dismiss pursuant to Rule 12(b)(6), the court may consider any documents attached to the complaint and statements or documents incorporated into the complaint by reference. The tolling agreement expressly referenced in the amended complaint has been...
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